4 


lEx  ICthrts 


SEYMOUR  DURST 


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Because  it  has  heen  said 
" Ever'thing  comes  t'  him  who  waits 

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THE 

CHOLERA  ASPHYXIA 

OF  NEW-YORK. 


\v  VS--    ■  . 


LETTERS 

OX  THE 

CHOLERA  ASPHYXIA, 


AS  IT  HAS  APPEARED 


IN  THE  CITY  OF  NEW-YORK  : 


ADDRESSED  TO  JOHN  C.    WARREN,  M.  D.,  OF  BOSTON,  AND  ORIGINALLY 
PUBLISHED  IN  THAT  CITY. 


TOGETHER  WITH 


OTHER  LETTERS,  NOT  BEFORE  PUBLISHED. 


BY  MARTYN  PAINE,  M.  D. 


PUBLISHED  BY  COLLINS  &  HANNAY. 

Clayton      Van  Norden,  Printers. 


1832. 


ExTERED  according  to  the  Act  of  Congress,  in  the  year  one  thousand 
eight  hundred  and  thirty-two,  by  Collins  &,  Hanxay,  in  the  Clerk's  Office 
of  the  District  Court  of  the  United  States,  for  the  Southern  District  of 
New- York. 


TO  THE  READER. 


When  I  addressed  the  first  of  the  following  Letters 
to  the  distinguished  gentleman  with  whom  I  prepared 
for  my  profession,  1  was  influenced  principally  by  the  de- 
sire, so  natural  and  common  to  pupils,  to  repay  by  every 
means  in  their  power,  and  if  possible,  however  slightly, 
in  kind,  the  unlimited  debt  which  they  owe  to  their  in- 
structors. The  early  appearance  of  the  Cholera  in  New- 
York,  a  disease  before  unknown  in  our  country,  afford- 
ed an  opportunity  for  the  humblest  among  us,  to  com- 
municate information  which  might  be  interesting,  and 
perhaps  useful,  to  the  most  skilful  and  learned  and 
eminent  in  other  cities.  And  I  could  not  but  appre- 
hend, that  this  inscrutable  and  relentless  stranger  would, 
in  his  arbitrary  and  fearful  progress,  visit  Boston,  where 
I  have  many  friendships  and  near  attachments.  The  lit- 
tle therefore  that  I  could,  by  diligent  observation,  learn 
of  the  Cholera,  I  was  irresistibly  impelled  to  communicate 
to  one  to  whom  all  in  that  city  look  for  professional  aid 


vi 


or  instruction.  But  I  had  not  the  most  distant  expecta- 
tion, that  my  letters  would  meet  the  public  eye,  nor 
would  my  own  judgment  have  led  to  their  publication. 
I  will  not,  however,  deny  the  gratification  I  felt,  at  learn- 
ing that  their  publication  had  been  deemed  useful  by 
one,  whose  approbation  I  have  ever  wished  to  deserve. 
The  first  four  letters  appeared  originally  in  the  Boston 
Daily  Advertiser  and  Patriot,  and  in  the  Boston  Weekly 
Messenger  and  Massachusetts  Journal,  and  it  was  not 
until  after  they  had  been  published  in  those  papers,  that 
the  idea  was  suggested  to  me  of  offering  them  to  the 
public  in  their  present  form.  As  soon  as  I  had  adopted 
this  suggestion,  I  thought  it  would  be  better  to  reserve 
the  remainder  of  the  letters,  until  the  whole  should  be 
published  together,  and  the  fifth  and  sixth  letters  are  ac- 
cordingly now  for  the  first  time  presented  to  the  public. 

I  am  sensible  that  these  letters  can  possess  no  other 
value  than  such  as  they  derive  from  my  means  of  ob- 
servation, and  the  diligence  with  which  they  have  been 
improved.  I  ought,  therefore,  to  say,  that  from  the  first 
appearance  of  the  disease  in  this  city  I  have  sought  it  at 
all  times  and  in  all  places,  and  indeed  much  more  con- 
stantly than  was  consistent  with  my  health,  and  ordinary 
engagements.  In  connexion  with  two  medical  friends, 
I  made,  on  the  second  of  July,  a  minute  post  mortem 
examination  of  two  of  the  first  who  fell  victims  to  the 


vii 


disease,  and  which  were  the  two  first  dissections  made 
in  the  United  States.    These  examinations  are  fully 
described  in  the  seventh  letter,  which  was  originally 
published  in  the  New-England  Medical  and  Surgical 
Journal.    Since  then,  besides  my  own  private  practice, 
I  have  daily  visited  as  many  of  the  hospitals  as  my  en- 
gagements would  admit  of,  and  have  made  and  witness- 
ed numerous  dissections.    To  have  described  these  va- 
rious post  mortem  examinations  would  have  been  an  un- 
necessary repetition  of  similar  appearances.    I  have 
thought  it  worth  while  to  preserve  only  such  cases  as 
would  exhibit  the  several  varieties  of  symptoms  which 
have  passed  under  my  observation.    These  will  be  found 
in  the  eighth,  ninth  and  tenth  letters,  which  have  also 
been  published  in  the  Medical  Journal.    One  of  these 
also  announces  the  important  discovery  by  Dr.  Gale,  a" 
scientific  chemist  of  this  city,  of  oil  existing  in  a  free 
state  in  the  blood  of  Cholera  subjects. 

The  letters,  except  those  describing  the  dissections, 
are  printed  in  the  order  in  which  they  were  written.  The 
parts  of  the  subject  of  which  they  treat  cannot,  there- 
fore, be  expected  to  be  formally  or  methodically  ar- 
ranged. Each  letter  was  however  designed  to  embrace 
a  single  topic.  The  first  presents  a  general  view  of  the 
disease ;  the  second  relates  to  the  nature  and  treatment 
of  premonitory  symptoms ;  the  third  to  the  importance 


viii 

of  attention  to  food,  as  a  means  of  prevention  ;  the 
fourth  to  the  treatment  of  Asphyxiated  Cholera ;  the 
fifth  to  the  nature  and  philosophy  of  the  disease  ;  and 
the  sixth  gives  a  circumstantial  account  of  its  symptoms 
as  they  appeared  in  this  city.  The  other  letters  con- 
tain the  dissections. 

I  trust  I  need  not  apologize  for  those  occasional  repe- 
titions and  other  faults,  vi^hich  are  almost  incident  to 
letter  vi^riting.  But  I  cannot  but  regret,  that  the  more 
impaired  condition  of  my  health  has  unfitted  me  for  the 
task  of  completing  the  letters  as  I  wished  to  have  done, 
and  forbade  any  thing  like  the  revisal  and  correction 
which  they  required.  Less  than  this  I  could  not,  and 
more  I  need  not  say,  to  a  candid  public. 

New- York,  September  14th,  1832. 


LETTER  1. 


New-Yokk,  August  lOi/i,  1832. 

Dear  Sir, 

I  HAD  intended  to  have  earlier  acknowledged 
your  very  flattering  attentions,  and  to  have  ex- 
pressed the  interest  and  instruction  with  which  I 
perused  the  Report  of  the  Massachusetts  Medical 
Society ;  which,  although  purporting  to  express 
the  opinions  of  others,  is  undoubtedly  one  of  the 
best  original  essays  which  has  appeared  on  the 
subject  of  Cholera  Asphyxia.  This  delay,  how- 
ever, enables  me  to  add  a  few  words  in  relation 
to  the  disease  as  it  has  appeared  in  this  city, 
which  I  do,  not  from  their  novelty,  but  to  show 
you  how  Nature  and  Art  have  still  travelled  the 
beaten  path. 

Tho  Cholera  Asphyxia  has  presented  to  our 
observation  the  same  combination  of  phenomena 
that  has  distinguished  the  Epidemic  in  other  quar- 
ters of  the  globe  ;  and  when  the  varieties  of  con- 
stitutions, the  differences  in  habits,  sex,  age,  &c. 
are  duly  considered,  the  symptoms  are  remarkably 
uniform,  particularly  after  asphyxia  has  super- 
vened. The  disease  has  been  less  malignant  here 
than  at  Montreal  and  at  Paris,  which  is  probably 
to  be  ascribed  to  the  better  ventilation  and  greater 
cleanliness  of  our  city  ;  for  your  own  observation 

2 


10 


will-  yet  assure  you,  that  the  disease,  at  least  in 
cities,  requires  for  its  production  the  co-opera- 
tion of  local  miasmata  with  the  general  epidemic 
poison;  and  doubtless  the  same  local  dcvelope- 
ments  give  intensity  to  the  poison  wherever  it 
prevails.  Well  favoured  cities,  therefore,  with 
spacious  streets,  and  especially  where  a  proper 
attention  is  paid  to  the  cleanliness  of  yards, 
houses,  &c.,  and  in  which  a  crowded  population 
is  not  permitted  during  the  visitation  of  the  Epi- 
demic, may  expect  to  reap  a  rich  reward  from 
measures  that  are  so  clearly  dictated  by  expe- 
rience and  philosophy.  In  New-York  we  may 
be  said  rather  to  have  suffered  several  endemics 
than  a  general  epidemic.  The  epidemic  poison 
has  not  been  sufficiently  active  to  produce  a  full 
predisposition  to  the  disease,  without  the  co-ope- 
ration of  local  causes.  It  has  been  confined  to 
the  malarious  part  of  the  town,  and  generally  to 
such  houses  as  are  small  and  crowded  with  inha- 
bitants,— in  some  instances  not  less  than  a  dozen 
in  one  house  having  died  in  rapid  succession. 

Although  we  may  recognise  in  a  very  striking 
degree  the  phenomena  of  the  Asiatic  disease,  they 
are  more  or  less  distinct  in  different  subjects  ; 
each  case,  however,  presenting  nearly  the  same 
combination.  The  symptoms  most  liable  to  modi- 
fication, are  lividness  and  collapse  of  the  fea- 
tures, these  being  more  frequently  absent  than 
has  been  remarked  in  other  countries.  Asphyxia, 
or  nearly  so,  is  a  uniform  symptom  of  the  stage 
of  collapse  ;  so  also  are  the  unequal  distribution 


11 


of  heat,  vomiting  and  purging, — almost  invariably 
of  a  fluid  resembling  rice  water,- — very  generally 
spasms,  cold  sweat,  corrugated  skin  and  blueness 
of  the  fingerS;  cold  tongue,  cold  breath,  suppres- 
sion of  the  glandular  secretions,  &c. 

The  morbid  appearances  on  dissection  have 
been  less  uniform  than  the  symptoms,  and  our 
pathology  has  been  consequently  much  embar- 
rassed.   The  small  intestines  commonly  exhibit 
some  appearances  of  congestion  either  of  the 
mucous  or  serous  coat,  generally  of  the  former  ; 
the  large  intestines  commonly  blanched,  especial- 
ly if  the  diarrhoea  has  been  profuse  ;  the  stomach 
nearly  natural ;  liver  sometimes  greatly  injected, 
but  often  very  natural ;  kidneys,  spleen,  and  pan- 
creas natural ;  bladder  empty  and  generally  con- 
tracted.   The  gall  bladder  contains  from  one  to 
two  ounces  of  black,  green  or  yellow  bile.  There 
is  generally,  though  not  always,  an  absence  of 
this  fluid  in  the  intestines,  which  usually  contain 
a  substance  similar  to  that  evacuated  during  life. 
It  has  been  well  compared  to  rice  water,  with 
flocculent  matter, -which  is  soon  deposited.  The 
texture  of  the  small  intestines,  particularly,  is 
often  softened,  which  has  induced  some  physi- 
cians to  ascribe  this  result  to  a  violent  inflamma- 
tion of  these  organs,  and  to  regard  this  action  as 
the  proximate  cause  of  the  disease.  But  so  far  as 
symptoms  and  appearances,  that  usually  denote 
inflammation,  are  necessary  to  this  theory,  they 
are  certainly   nearly  ^vanting  in  Cholera  As- 
phyxia,— venous  congestion  being  almost  the 


12 


only  sensible  condition  of  the  blood-vessels. 
Both  cavities  of  the  heart  are  sometimes  filled 
with  black  blood,  and  they  are  sometimes  empty, 
— appearances  which  also  attend  the  lungs.  The 
brain  is  more  uniformly  injected  than  any  other 
organ,  and  usually  contains,  either  in  the  ventri- 
cles, or  w^ithin  its  membranes,  a  preternatural 
quantity  of  serum  ;  yet  the  integrity  of  the  mind 
is  not  much  impaired.  The  veins  of  the  spinal 
sheath  are  also  commonly  full. 

Here,  as  every  where  else,  the  disease  was 
most  malignant  at  its  irruption,  and  has  become 
milder  as  the  epidemic  air  has  abated.  Most  of 
the  subjects  perished,  at  first ;  and  our  greater 
success,  now,  arises  from  the  milder  condition  of 
the  disease,  from  a  longer  duration  of  the  pre- 
monitory symptoms,  and  from  the  more  suscepti- 
ble class  having  been  swept  away.  The  nature  and 
treatment  of  the  epidemic  are  probably  no  better 
understood  than  when  it  first  invaded  Europe: 
The  Asiatic  physicians  appear  to  have  exhausted 
the  subject,  and  the  more  we  have  departed  from 
their  modes  of  treatment,  the  less  successful  have 
been  the  results.  It  is  certain  that  the  disease 
was  less  fatal  in  Asia,  where  it  is  supposed  to 
have  been  most  malignant ;  and  it  has  been  de- 
structive in  an  increasing  ratio  ever  since  it  ap- 
peared in  Europe.  At  Quebec  and  at  Montreal 
scarcely  any  recover,  at  this  late  period,  after  the 
accession  of  Asphyxia.  Here  the  disease  having 
been  milder,  the  recoveries,  after  that  stage,  have 
probably  been  about  one  in  six.    If  the  habits  of 


13 


the  patient  have  been  regular  and  temperate, 
perhaps  it  is  one  to  four  or  five  that  he  will  re- 
cover, if  asphyxia  have  not  existed  more  than  one 
hour  ;  but  no  such  good  fortune  awaits  the  in- 
temperate. The  noise  which  he  hears  is  his  fu- 
neral knell. 

I  have  not  remarked  that  changes  of  tempera- 
ture or  atmospheric  phenomena,  have  exerted 
much  influence  on  the  character  of  the  epidemic. 
It  seems  to  have  been  governed  by  its  peculiar 
laws,  which  have  been  scarcely  modified  by  acci- 
dent. The  irruption  took  place  when  the  wea- 
ther was  delightfully  serene,  and  the  city  most  re- 
markably exempt  from  disease.  Diarrhoea  had 
not  even  preceded  it ;  and  it  was  an  astonishing 
spectacle  to  witness  the  work  of  the  destroyer 
without  the  usual  admonitions  of  his  approach. 
It  was  then  that  we  had  Death  and  not  disease 
in  our  city.  His  march  was  rapid,  under  a 
cloudless  sky  and  a  most  genial  temperature  ; 
and  the  mortality  acquired  its  maximum  during 
this  seemingly  auspicious  state  of  the  atmosphere. 
There  then  began  a  decreasing  ratio,  the  wea- 
ther and  temperature  becoming  more  variable,  and 
the  present  storm,  which  has  continued  a  week, 
seems  not  to  have  retarded  its  decline  in  the  city; 
while  in  the  neighbouring  country  the  disease  is 
appearing  most  malignantly  under  the  same  con- 
ditions of  the  atmosphere. 

What  are  the  exciting  causes  ?  It  has  been 
very  rare,  if  it  has  ever  happened  in  this  city, 
that  the  epidemic  poison  has  done  more  than 


14 


predispose  the  system.  Other  causes  have  been 
necessary  to  the  developement  of  the  disease,  and 
perhaps  none  have  acted  with  greater  intensity 
than  the  exhalations  which  arise  from  filth  and 
decaying  materials.  Indeed,  the  agency  of  these 
causes  appears  to  have  been  almost  indispensa- 
ble, for  few  have  suffered  the  disease  who  have 
lived  temperately  and  prudently  without  the  ma- 
larious districts.  Consequently  the  disease  has 
chiefly  prevailed,  and  deaths  have  principally  oc- 
curred, among  the  most  abject  of  the  lower  or- 
ders,— attacking  constitutions  that  have  been 
rendered  susceptible  by  vicious  habits  or  broken 
down  by  disease.  Still  we  have  lost  some  valu- 
able citizens,  whose  habits  were  temperate,  and 
whose  lives  were  exemplary  ;  but  let  us  convert 
their  loss  to  at  least  one  good  purpose;  let  us 
avoid  those  exciting  causes  which,  in  almost 
every  instance,  have  sent  them  prematurely  to  the 
grave.  These  causes  have  generally  consisted  in 
some  kinds  of  indigestible  food  ;  what  in  ordinary 
conditions  of  the  atmosphere  are  inoffensive,  but 
which  are  death  to  a  subject  predisposed  to  cho- 
lera. Garden  vegetables,  and  almost  every 
species  of  fruit,  have  been  known  to  develope  the 
disease  ;  and  the  prudent  part  of  our  population 
now  restrict  themselves  to  lean  fresh  meat,  po- 
tatoes, boiled  rice,  stale  bread,  eggs,  milk,  butter, 
tea  and  coff'ee,  and  it  is  considered  hazardous  to 
extend  the  variety.  Fatigue,  imperfect  clothing, 
currents  of  air,  exposure  to  the  rain,  and  depress- 
ing passions  of  the  mind,  have  been  known  to 
create  the  cholera. 


15 


We  have  not  been  able  to  add  any  thing  new 
to  what  has  been  long  known,  or  rather  unknown, 
respecting  the  proximate  cause  of  the  malady. 
Most  of  us  are  well  satisfied  that  it  possesses 
nothing  in  common  with  the  ordinary  cholera 
morbus,  but  that  the  diseases  are  essentially  dis- 
tinct. The  hypotheses  are  very  various ;  some 
regarding  it  as  a  local  affection,  and  others  as  con- 
stitutional ;  some  referring  it  to  a  primary  inflam- 
mation, congestion,  or  some  unknown  modifica- 
tion of  the  action  of  the  alimentary  canal  ;  others 
to  congestion  of  the  brain,  or  of  the  spinal  marrow 
and  ganglia ;  while  others  look  alone  at  the  di- 
minished glandular  secretions, — and  still  another 
places  the  whole  mischief  in  the  carbonization  of 
the  blood; — and  yet  another  regards  the  ab- 
sence of  the  saline  principles  as  the  sine  qua  non. 
To  me,  however,  the  disease  is  just  as  obviously 
a  constitutional  one.  We  have  frequently  wit- 
nessed the  invasion  of  asphyxia,  without  any 
premonitory  symptoms,  when  it  has  been  suffi- 
ciently apparent  that  all  the  functions  and  all 
the  powers  have  been  simultaneously  affected.  If 
this  hypothesis  be  true,  we  shall  understand  why 
one  important  organ  is  at  one  time  apparently 
sustaining  much  of  the  burthen  of  morbid  action, 
and  at  another  none  at  all.  From  so  great  a  di- 
versity of  opinion  respecting  the  proximate  cause 
of  cholera  there  would  necessarily  result  a  great 
diversity  of  treatment;  but  the  variety  of  means 
employed  very  evidently  arises,  in  part,  from  the 
want  of  success  which  attends  every  method.  We 


16 


have  no  difficulty  with  the  disease  in  its  prelimi- 
nary stages  ;  but  after  asphyxia  has  fairly  super- 
vened, I  do  not  believe  that  one  patient  in  six  is 
restored  by  any  process,  whatever  may  have  been 
asserted  on  this  subject.  1  have  seen  much  of  the 
disease,  and  have  looked  at  it  impartially ;  and  I 
express  a  solemn  conviction  on  the  subject  of  its 
fatality.  I  have  seen  every  method  tried,  and  in 
some  I  have  no  confidence  at  all.  I  have  none  in 
what  has  been  denominated  the  camphor  treat- 
ment^ exclusively ;  none  in  the  exclusive  use  of 
ice  internally.  I  have  seen  the  best  results  from 
powerful  external  stimulants ; — calomel  more  or 
less  modified  by  small  quantities  of  opium,  accord- 
ing to  the  irritability  of  the  mucous  membrane, 
and  camphor  is  a  useful  addition  if  spasms  be 
present ;  friction  with  camphor,  or  applications 
of  ice  for  the  relief  of  spasm  ;  stimulants  mode- 
rately to  sustain  the  sinking  powers,  of  which 
ammonia  seems  the  best.  The  irritability  of  the 
mucous  membrane  is  easily  allayed,  and  is  very 
rarely  an  obstinate  symptom, — the  most  promi- 
nent, during  the  stage  of  asphyxia,  being  the  ab- 
sence of  pulse,  unequal  distribution  of  heat,  rest- 
lessness and  altered  expression  of  countenance. 
We  have  nearly  abandoned  transfusion,  from  its 
almost  uniform  failure.  The  recoveries  I  do  not 
think  have  been  in  the  ratio  of  two  to  fifty.  The 
temporary  eflTect  is  very  encouraging,  but  the 
patients  soon  die.  Our  best  practitioners  employ 
calomel  in  large  and  small  doses,  some  preferring 
15  to  25  grains  once  in  three  or  four  hours,  and 


17 


others  five  grains  every  hour.  I  have  seen  no 
good  effect  from  blood-letting  in  any  instance  after 
asphyxia;  but  this  may  have  arisen  from  the  quan- 
tity having  been  small,  and  the  difficulty  with 
w^hich  it  is  invariably  abstracted.  From  the  pa- 
thology of  the  disease,  and  the  experience  of  the 
Asiatic  physicians,  I  have  been  in  favour  of  the 
remedy. 

I  regret  that  my  time  will  not  permit  me  to  add 
more  at  present.  Your  citizens  ought  to  be  well 
informed  of  the  fatality  of  the  disease  after  the 
stage  of  asphyxia,  and  of  its  mildness  before  that 
stage  supervenes,  that  they  may  be  early  induced 
to  attend  to  the  premonitory  symptoms. 

Very  respectfully,  &/C. 


3 


18 


LETTER  II. 


New- York,  August  IStli,  1833. 

Dkar  Sik, 

I  HAD  yesterday  the  pleasure  of  receiving  your 
favour  of  the  15th  inst.,  and  I  was  certainly  agree- 
ably surprised,  that  my  remarks  on  the  subject  of 
Cholera  Asphyxia  should  have  afforded  you  the 
interest  you  do  me  the  honour  to  express,  and  more 
particularly  that  you  considered  them  worthy  of 
publication.    In  relation  to  your  inquiries  respect- 
ing the  symptoms  which  have  marked  the  acces- 
sion of  the  Cholera  in  this  city,  there  exists  here, 
as  in  other  countries,  the  remarkable  fact,  that  the 
earliest  manifestations  of  disease  are  almost  uni- 
formly mild,  and  bear  no  corresponding  ratio  to 
the  tremendous  developement  which  suddenly  suc- 
ceeds after  a  certain  duration  of  that  premonitory 
stage.     This  introductory  stage  is  very  rarely 
wanting,  and  its  duration  and  symptoms  depend 
much  on  temperament  and  habits.    The  symp- 
toms generally  denote  some  impaired  function  of 
the  digestive  organs,  and  usually  consist  of  diar- 
rhoea, frequently  connected  with  nausea  and  vomit- 
ing.   This  condition  in  many  instances  is  pre- 
ceded by  constipation,  which,  however,  is  not  so 
uniform  as  has  been  imagined,  but  which,  if  ne- 
glected, is  very  liable  to  result  in  diarrhoea.  There 


19 


is,  indeed,  a  general  tendency  to  looseness  of  the 
bowels,  and  they,  who  have  been  habitually  com- 
pelled to  employ  some  laxative  medicine,  find  now 
an  ample  substitute  in  the  epidemic  influence. 
This  is  a  fact,  which,  I  think,  cannot  be  too  well 
understood  ;  for  it  is  this  impaired  state  of  the 
digestive  organs,  this  tendency  in  all  to  looseness 
and  diarrhoea,  which  have  rendered  our  precau- 
tions in  relation  to  food  so  indispensable,  and 
which,  when  disregarded,  have  taught  a  lesson  of 
prudence  that  few  would  have  heeded,  but  for  the 
terrible  penalty  so  evidently  connected  with  the 
indulgence.  If  the  habits  of  the  patient  have  been 
prudent,  especially  in  respect  to  food,  the  diarrhoea 
is  moderate,  continuing,  if  it  terminate  in  malig- 
nant cholera,  for  many  days  without  vomiting,  and 
not  productive  of  much  prostration  or  distress,  till 
collapse  suddenly  supervenes.  If  indigestible  food 
be  the  exciting  cause  in  a  temperate  subject 
strongly  predisposed,  vomiting  is  an  early  symp- 
tom ;  which,  however  subsides,  and  there  only 
remains  for  a  while,  the  diarrhoea,  afterwards 
maintained  by  slighter  errors  in  diet,  till  it  sooner 
results  in  Asphyxia  than  in  more  abstemious  sub- 
jects. I  have  not  observed  that  constitutions  im- 
paired by  disease,  where  great  prudence  has  been 
practised,  are  more  obnoxious  to  cholera,  or  that 
collapse  sooner  succeeds  the  premonitory  stage 
than  in  the  robust.  Particular  circumstances  have 
led  me  to  attend  closely  to  this  fact,  and  my  ob- 
servations on  this  subject  do  not  concur  with  book 
authority.   But  it  is  equally  true  that  constitutions, 


20 


impaired  by  inlcmperance  and  prostitution,  are 
peculiarly  the  subjects  of  this  pestilence  ;  and  I 
cannot  agree  with  Mr.  Fife  of  Gateshead,  "that 
drunkenness  is  not  a  powerful  predisposing  cause," 
though  doubtless  very  much  is  to  be  ascribed  to 
the  influence  of  other  accidental  causes, — particu- 
larly excesses  in  food,  and  the  filth  in  which  they 
riot.  The  succession  of  primary  symptoms  is 
more  rapid  in  such  instances ;  but  still  there  is 
commonly  a  period  for  the  successful  intervention 
of  art,  but  which  is  generally  neglected.  The 
aged  sink  quickly  under  the  diarrhoea,  if  the  chole- 
ric predisposition  exist;  and  children,  though  not 
often  attacked,  pass  rapidly  through  the  several 
stages  of  the  disease  to  a  fatal  termination.  Diar- 
rhoea and  vomiting  do  not  always  distinguish  the 
premonitory  stage  ;  but  it  is  sometimes  denoted 
only  by  headacli,  loss  of  appetite,  oppression  at 
the  chest,  &c.  and  again  spasms  are  known  to 
have  been  the  earliest  symptom,  and  at  first  the 
only  prominent  one,  and  susceptible  of  relief. 
During  the  existence  of  diarrhoea,  the  appetite 
often  remains  unimpaired,  and  I  have  frequently 
known  it  to  have  been  morbidly  increased  just* 
before  the  occurrence  of  that  symptom,  and  the 
pati(^nts  have  sunken  rapidly  into  an  incurable 
asphyxia.  Something,  no  doubt,  is  to  be  ascribed 
in  such  instances,  in  explaining  the  accelerated 
march  of  the  disease,  to  tlie  morbid  indulgence. 

Much  may  be  said  on  this  very  interesting  sub- 
ject of  premonitory  symptoms,  on  which  are  sus- 
pended the  life  of  the  patient  and  the  happiness 


21 


of  friends,  and  which  may  determine  the  fate  of 
both,  as  they  may  be  duly  noticed  or  disregarded.  It 
is  certain,  however,  that  it  is  not  one  of  the  least 
attendant  phenomena,  that  the  patient,  whose  fears 
had  been  before  sensitive  on  the  subject  of  the 
epidemic,  becomes  seemingly  indifferent  after  the 
invasion  of  the  earliest  stage,  and  is  wholly  re- 
gardless of  life  when  he  approaches  the  more 
alarming  crisis.  This  apparent  apathy  has  been 
ascribed,  you  are  aware,  to  a  disinclination  to  avow 
the  apprehension,  that  the  king  of  terrors  has  at 
length  made  his  approach  where  most  dreaded  ; 
but  I  cannot  think  that  the  true  cause  has  been  as- 
signed. It  is  a  symptom  hclongiiig  to  the  disease, 
and  I  have  frequently  experienced  a  great  difficulty 
in  exciting  the  fears  of  intelligent  patients  so  far 
as  to  induce  them  to  submit  to  the  necessary  reme- 
dies and  a  proper  abstinence  from  food.  It  is  a 
condition  of  the  mind,  also,  which  is  progressive 
with  the  disease,  and  I  have  rarely  heard  of  the 
least  solicitude  being  manifested,  after  the  formi- 
dable stage  has  supervened. 

The  premonitory  symptoms,  here  as  elsewhere, 
were  of  comparatively  short  duration  at  the  irrup- 
tion of  the  epidemic,  at  which  time  death  ensued 
in  a  few  hours  after  the  attack. 

The  treatment  of  this  epidemic,  in  its  incipient 
stage,  must,  of  course,  be  determined  by  the  par- 
ticular symptoms  of  the  case,  the  probable  strength 
of  the  predisposition,  general  circumstances  of  the 
patient,  &c.  From  the  impaired  condition  of  the 
digestive  functions,  it  is  indispensable  in  all  cases 


22 


to  discontinue  solid  food,  and  to  limit  the  quantity 
of  farinaceous  fluids. 

1st.  If  tlic  subject  be  of  temperate  habits,  the 
tongue  clean  or  slightly  coated,  the  evacuations 
not  particularly  morbid  nor  frequent,  and  no  vomit- 
ing, it  will  be  generally  sufficient  to  stop  the  solid 
food  ;  or  a  small  dose  of  castor  oil,  or  of  rhubarb 
and  magnesia,  will  be  all  the  medicine  that  will  be 
indicated.  If  the  diarrhoea  be  more  urgent,  deno- 
ting a  more  irritable  state  of  the  mucous  mem- 
brane, probably  two  teaspoonsful  of  paregoric 
should  be  at  once  given,  and  another  after  each  sub- 
sequent evacuation.  A  continued  abstinence  from 
solid  food  for  a  short  time  will  supersede  the  ne- 
cessity  of  a  cathartic,  where  the  bowels  have  been 
so  thoroughly  evacuated  as  a  consequence  of  dis- 
ease. The  irritability  of  the  mucous  membrane  is 
easily  allayed  at  almost  every  period,  and  vomiting 
and  purging  arrested  without  much  difficulty  ;  and 
I  have  found  paregoric  the  best  remedy  for  that 
purpose  when  these  symptoms  are  not  violent. 

2d.  The  next  most  simple  combination  of  pre- 
monitory symptoms  proceeds  from  some  error  in 
Jood,  the  most  common  of  all  exciting  causes.  If 
there  exist  much  nausea,  or  imperfect  vomiting,  and 
the  food  have  not  evidently  passed  from  the  sto- 
mach, the  patient  will  be  immediately  relieved  by 
a  mild  emetic  of  ipecacuanha,  associated  with  calo- 
mel enough  to  act  as  a  cathartic.  The  organs  of 
digestion  are  thus  unloaded,  and  the  predisposition 
to  disease  at  once  subdued.  The  patient  should 
be  afterwards  restricted  to  broth  or  gruel,  till  the 
symptoms  shall  have  been  absent  for  a  day  or  two. 


23 


If  a  patient,  who  lias  thus  erred,  be  not  seen 
till  the  contents  of  the  stomach  have  been  eject- 
ed, or  have  passed  into  the  bowels,  emetics  are 
not  indicated,  for  we  have  seen  no  benefit  arising 
from  them,  except  at  the  very  invasion,  and  for 
the  purpose  of  evacuating  the  stomach.    At  later 
periods  they  are  nearly  sure  to  kill.    If  the  di- 
arrhoea be  now  only  moderate,  and  the  evacua- 
tions not  presenting  the  characteristic  appear- 
ance of  malignancy,  and  the  vomiting  have  ceas- 
ed, a  dose  of  rhubarb  and  magnesia  will  proba- 
bly suffice.    But  if  vomiting  continue  with  obsti- 
nacy, a  stronger  predisposition  is  shown,  and 
calomel  modified  by  a  grain  or  less  of  opium  and 
one  or  two  grains  of  camphor,  is  indicated  ;  and 
if  the  discharges  be  not  soon  arrested,  more 
opium  should  be  given,  and  the  calomel  repeat- 
ed once  or   twice  if  the  secretions  have  ap- 
peared morbid,  till  the  bowels  are  again  moved. 
Or,  when  I  think  I  have  obtained  a  sufficient 
advantage  from  the  specific  action  of  that  reme- 
dy, and  it  has  not  produced  a  cathartic  effect,  I 
suspend  its  exhibition  and  await  that  result  for 
some  hours  ;  or,  if  there  be  any  motive  for  an 
early  movement  of  the  bowels,  I  exhibit  a  dose 
of  castor  oil.    It  frequently  happens  that  the  di- 
rect operation  of  a  cathartic,  at  the  very  invasion 
of  the  disease,  will  alone  arrest  its  progress  ;  but 
after  a  delay  of  a  few  hours,  the  mucous  mem- 
brane may  have  acquired  a  degree  of  irritability 
that  must  essentially  modify  the  practice. 

The  quantity  of  calomel  which  I  exhibit  at  a 


24 


dose  in  the  premonitory  stages  varies  from  10  to 
25  grains, — generally  about  20  grains.  But  I 
have  observed  a  great  difference  in  the  action  of 
calomel  and  other  cathartics  in  the  diseases  of 
Boston  and  Montreal  and  those  of  this  climate. 
Here  we  are  more  subject  to  congestive  affections 
of  the  liver  and  the  abdominal  viscera,  and  more 
active  doses  are  more  advantageously  employed 
than  at  the  former  places. 

3d.  If  diarrhoea  suddenly  invade,  and  be  soon 
followed  by  vomiting,  without  any  obvious  cause, 
and  if  the  evacuations  be  serous,  and  resembling 
or  approaching  in  appearance  to  rice  water,  the 
attack  has  arisen  from  the  activity  of  the  predis- 
posing cause,  and  constitutes  a  formidable  case. 
Here  there  has  probably  been  a  gradual  acces- 
sion of  disease,  but  not  denoted  by  any  remark- 
able symptoms,  till  this  sudden  developement  of 
diarrhoea  and  vomiting.  In  such  a  case  the 
tongue  may  be  clean,  and  scarcely  any  other 
morbid  phenomena  than  the  intestinal  commo- 
tion and  the  serous  evacuations  to  admonish  us 
of  the  impending  danger.  If  the  pulse  be  not 
much  depressed,  this  is  a  case  for  blood-letting, 
and  perhaps  for  its  repetition.  At  the  same  mo- 
ment a  grain  of  opium  should  be  given,  and  re- 
peated once  in  20  to  60  minutes,  till  the  irrita- 
bility of  the  mucous  membrane  be  subdued.  A 
large  mustard  cataplasm  should  be  also  applied 
over  the  region  of  the  stomach  and  liver,  and  as 
soon  as  the  skin  is  irritated  by  that  means,  a 
large  blister  should  be  substituted.    Among  the 


25 


early  remedies,  calomel  should  not  be  neglect- 
ed, and  conjoined  with  opium  and  camphor  if 
the  vomiting  and  purging  continue  ;  and  it  will 
be  commonly  found  expedient  to  repeat  the  calo- 
mel*for  two  or  three  large  and  successive  doses. 
The  evacuations  will  become  very  dark  as  the 
disease  subsides.  His  convalescence  will  be 
gradual.  ^ 

4th.  Tf  the  patient  exhibit  a  white  tongue,  and 
diarrhcea  be  almost  the  only  other  attendant 
symptom,  he  will  probably  be  relieved  by  calomel 
alone.  He  will  require  particular  prudence,  how- 
ever, in  regard  to  food.  If  a  sense  of  oppres- 
sion at  the  chest  exist,  or  pain  in  the  head,  or 
soreness  at  the  region  of  the  stomach,  blood-let- 
ting will  be  indicated  ;  and  if  tenderness  of  the 
stomach  remain,  a  blister  or  leeches  applied  there 
will  accelerate  his  cure. 

5th.  It  sometimes  happens  that  the  earliest 
symptoms  consist  of  headach,  oppression  of  the 
prsecordia,  impaired  appetite,  and  coated  tongue. 
Blood-letting  and  cathartics  of  calomel  are  then 
required,  and  a  blister  over  the  region  of  the 
stomacli.  In  these  cases,  where  there  has  been 
no  diarrhoea,  the  first  evacuation  will  be  very 
dark. 

6th.  If  there  be  a  yellow  coating  of  the  tongue, 
and  purging  of  bilious  fluid,  with  or  without  vo- 
miting, the  case  is  a  favourable  one,  whatever 
the  exciting  cause,  and  requires  cathartics  of  ca- 
lomel and  oil.  I  have,  however,  seen  such  cases 
result  in  asphyxia,  and  terminate  in  death,  the  pa- 

4 


26 


tient  purging  and  vomiting  a  deep  yellow  or  a 
deep  greenish-yellow  bile  to  the  last  moment. 

7th.  Spasms  sometimes  introduce  the  disease, 
and  may  exist  for  some  hours,  unattended  by  any 
other  prominent  symptom.  They  have  not,  How- 
ever, I  believe,  constituted  a  difficult  case,  but 
have  soon  yielded  to  blood-letting  and  cathar- 
tics. They  sometimes  also  occur  in  connexion 
with  the  premonitory  symptoms  of  diarrhoea,  and 
require,  with  other  means  I  have  indicated,  stimu- 
lating embrocations,  friction,  &.c.  The  topical 
application  of  ice  is  also  excellent  for  the  relief  of 
spasm,  whether  in  the  premonitory  or  the  subse- 
quent stages  of  the  disease. 

8th.  There  is  occasionally,  from  the  access  of 
the  disease,  a  very  obstinate  determination  of 
blood  to  the  head,  and  palpable  inflammation  of 
the  brain.    In  such  instances  the  evacuations  in 
the  primary  stage  are  very  light,  or  do  not  occur 
at  all.    These  cases  require  decision  with  the  lan- 
cet, leeches  to  the  head,  removal  of  the  hair,  and 
cathartics  of  calomel  and  castor  oil.    The  dejec- 
tions become,  at  once,  very  dark,  and  frequent 
cathartics  will  be  necessary  in  the  progress  of  the 
cure.    These  casee  almost  always  yield  to  this 
treatment.    When  they  do  not,  or  are  neglected, 
vomiting  and  purging  of  the  characteristic  rice 
water  takes  place,  and  the  patient  passes  through 
the  stage  of  collapse  into  a  state  of  delirium. 

Whenever  vomiting  occurs  as  a  premonitory- 
symptom,  all  fluids  should  be  denied  the  patient. 
If  it  do  not  readily  yield  to  the  treatment  sug- 


27 


gested,  ice  held  in  the  mouth  will  be  found  a  use- 
ful auxiliary,  and  it  affords  the  advantage,  also, 
of  allaying  the  intolerable  thirst  which  is  some- 
times early  attendant  on  that  symptom. 

If  the  symptoms  denote  a  severe  grade  of  dis  - 
ease, salivation  will  hasten  convalescence,  and 
obviate  the  necessity  of  some  other  remedies. 

Although  the  predisposition  to  this  epidemic 
is  generally  developed  by  some  of  the  premonitory 
symptoms  which  I  have  indicated,  it  occasionally 
happens  that  the  attack  is  very  insidious.  The 
tongue  may  be  clean,  and  of  a  healthy  appear- 
ance :  the  evacuations  at  first  bilious,  and  unat- 
tended with  pain  ;  perhaps  little  or  no  vomiting 
and  no  evidence  of  danger  in  the  countenance  ; 
yet  I  have  known  a  sudden  transition  of  these 
auspicious  appearances  to  an  array  of  the  most 
malignant  symptoms. 

I  have  said  but  little  in  respect  to  the  state  of 
the  tongue  as  an  index  of  the  disease,  and  still  less 
of  the  pulse,  and  skin,  and  secretion  of  urine. 
They  are  so  variously  affected,  under  apparently 
the  same  circumstances,  that  they  cannot  be  as- 
sumed as  criteria.  The  tact  of  the  physician, 
therefore,  must  convert  them  to  the  best  advan- 
tage in  each  individual  case. 

The  patient  will  require  particular  instructions 
in  regard  to  food  during  his  convalescence,  as  he 
will  be  very  likely  to  yield  to  his  propensities. 

I  regret  that  my  time  will  not  allow  me  to  reply 
fully  to  your  letter,  but  I  will  drop  you  another  line 
this  evening,  and  communicate,  also,  the  results 
of  some  analyses  of  the  blood. 


28 


In  reply  to  your  inquiry,  I  have  had  no  symp- 
toms of  the  Cholera,  and  the  physicians  here  have 
been  generally  equally  exempt.  The  few  that 
have  died  perished  in  the  good  cause  of  humani- 
ty, and  were  the  victims  of  a  generous  ambition, 
that  prompted  them  to  exposures  which  no  consti- 
tution can  resist. 


Very  respectfully,  &c. 


29 


LETTER   11 1.^ 


New- York,  August  I9th,  1832. 

Dear  Sir, 

In  my  letter  to  you  yesterday,  explaining  the 
results  of  my  experience  in  the  treatment  of  the 
premonitory  symptoms  of  Cholera  Asphyxia,  I 
had  not  the  time  to  say  what  I  could  have  desi- 
red on  the  no  less  important  subject  of  the  ex- 
cittfig  causes  of  the  disease.  Having,  hovi^ever, 
adverted  in  a  former  communication  to  the  ge- 


*  This  letter  was  introduced  by  the  original  publisher  with  tlie 
following  remarks,  and  which  are  retained  for  obvious  reasons.  I 
need  not  say  that  T  entirely  concur  in  the  opinion  expressed  on  the 
subject  of  food. 

"  The  author  of  this  and  two  other  able  letters  on  the  same  sub- 
ject appears  to  disapprove  the  use  of  fruits  and  vegetables  during 
the  Cholera  season. 

"  On  this  opinion  it  may  be  remarked,  that  a  distinction  should 
be  made  between  a  place  where  Cholera  is  epidemic,  and  one  where 
it  is  expected  to  be  epidemic. 

*'  Where  the  epidemic  exists  no  one  should  eat  fruit  and  vegeta- 
bles, unless  the  state  of  the  digestive  organs  require  these  articles, 
and  then  with  all  possible  precaution  as  to  quantity  and  observation 
of  the  effect  produced. 

"  Where  the  Cholera  does  not  prevail,  the  constitution  of  the  at- 
mosphere, although  predisposing  to  the  epidemic,  need  not,  prevent 
a  prudent  tl^e  of  ripn  fruits  and  good  vegetables." 


30 


ncral  facts,  relating  to  this  inquiry,  which  have 
occurred  under  my  observation,  I  shall  now  con  - 
fine my  remarks  to  the  most  common  of  all  the 
exciting  causes  of  Cholera.    It  is  an  argument, 
d  priori,  that  the  varieties  of  food  and  the  mode- 
rate stimulants,  which  are  well  adapted  to  the 
healthy  system  in  ordinary  conditions  of  the  at- 
mosphere, can  scarcely  endanger  the  health  of  the 
being  they  were  destined  to  nourish,  under  any 
vicissitudes  of  the  natural  phenomena  of  the  ele- 
ments.   This  very  plausible  induction  has  ope- 
rated in  most  places  that  have  been  visited  by 
Cholera,  and  the  general  sentiment  has  been 
in  favour  of  a  moderate  indulgence  in  the  fruits 
of  the  earth,  and  the  luxuries  of  the  culinary  art. 
The  irruption  of  the  Epidemic,  however,  soon 
proved  to  us  the  fallacy  of  this  philosophy,  and 
the  experience  of  the  majority  has  been  conclu- 
sive against  many  species  of  food,  which  they 
had  hitherto  eaten  with  advantage.    The  fact 
has  been  even  appalling  to  the  most  incredulous 
epicure,  who  has  been  compelled  to  drop  his  ac- 
customed varieties,  as  they  have  been  returned, 
one  after  another,  from  his  stomach  undigested  ; 
or  if  perchance  this  organ  have  borne  the  indul- 
gence with  its  wonted  forbearance,  an  unusual 
tormina  of  his  bowels  has  startled  his  confidence 
in  the  vigour  of  his  digestive  powers.  Theory 
and  experience  all  give  way  to  the  overwhelming 
argument  of  a  choleric  atmosphere.    The  con- 
stipated dyspeptic  abandons  his  bolus  of  soap 
and  aloes,  and  condemns  unbolted  flour  as  a 


31 


purgative  diet  ;  and  even  the  shampooing  of 
Halsted  threatens  him  with  hyper-catharsis. 
The  doctors,  who  tickle  the  palates  of  their 
patients,  are  thrown  into  confusion,  and  some 
are  alarmed  lest  it  should  lend  a  fact  to  ano- 
ther class,  who  regard  the  subject  of  food  as 
an  important  part  of  the  methodus  medendi  in 
diseases  of  the  digestive  organs.  The  epidemic 
influence,  however,  cannot  be  resisted,  and  there 
soon  prevails  a  remarkable  unanimity  in  regard 
to  the  impaired  condition  of  the  digestive  func- 
tions, and  the  necessity  of  abstinence  from  many 
common  articles  of  food.  In  short,  there  is  an 
internal  impression  produced  on  every  one,  which 
admonishes  him  that  he  is  more  than  usually  vul- 
nerable. The  epidemic  poison  creates,  almost 
universally,  an  irritable  state  of  the  stomach  and 
bowels,  of  which  very  few  are  aware  without  an 
experiment,  but,  which  is,  however,  commonly 
made  ;  and  the  issue  will  depend  on  the  extent  of 
the  indulgence.  Even  the  habitual  drunkard 
glides  safely  along  by  abstaining  from  his  accus- 
tomed liquor,  and  observing  a  rigorous  diet ;  and 
it  has  been  constantly  observed  that  in  those  sub- 
jects, the  immediate  exciting  cause  has  been 
rather  some  indigestible  food,  than  the  inebriating 
poison.  It  is  undoubtedly  important  to  obviate 
constipation  ;  but  this  is  rarely  a  difiiculty  in  cho- 
lera times,  and  should  be  done  by  medicine  rather 
than  by  food.  The  former,  judiciously  applied, 
is  safe,  the  latter  is  attended  with  danger.  The 
necessity  of  precaution  in  respect  lo  ingesta  will 


32 


be  more  or  less  modified  by  the  intensity  of  the 
predisposing  causes.  In  this  city  it  has  extended, 
by  common  consent,  to  all  garden  vegetables  and 
to  ail  ripe  fruits  ;  to  pastry,  puddings,  cheese,  and 
all  the  et  ceteras  which  are  not  included  in  the 
following  bill  of  fare.  A  healthy,  robust  man  sits 
down  to  a  breakfast  of  stale  bread,  butter,  boiled 
eggs,  and  tea  or  coffee,  or  milk. — His  dinner  is 
constituted  of  some  fresh  animal  food,  light  mealy 
potatoes,  boiled  rice,  stale  bread,  eggs  and  a  glass 
of  water — perhaps  of  wine.  For  tea, — he  con- 
tents himself  with  toast  and  tea  alone.  This  is 
technically  called  a  cholera  table,"  and  prevails 
not  only  in  private,  but  in  many  public  houses. 
Not  only,  therefore,  has  it  well  been  said  that  the 
Cholera  is  the  "  Apostle  of  Temperance,"  but  it 
has  taught  mankind  a  lesson  on  sensual  indul- 
gences, which  will  not  be  soon  forgotten. 

The  great  objection  to  fruit  arises  from  the 
direct  irritation,  produced  by  its  constituent  acid, 
and  from  its  particular  liability  to  fermentation 
during  the  epidemic.  I  have  known  whortle- 
berries to  have  simultaneously  developed  the 
cholera  in  five  temperate  and  healthy  members  of 
one  family,  (the  Bogart  family,)  who  were  all 
gathered  to  the  tomb  ere  the  setting  of  that  sun 
which  rose  upon  their  sufferings. 

Dr.  Gale,  a  very  intelligent  chemist  in  this  city, 
is  engaged  in  a  series  of  experiments  on  the 
blood  of  Choleric  patients.  He  has  supplied  me 
with  the  following  facts  which  may  interest  you; 

In  eight  analyses  of  cholera  blood,"  he  says, 


33 


there  has  been  a  universal  diminution  of  water, 
being,  in  some  cases  twenty  per  cent,  and  in  one 
twenty  below  the  ordinary  standard,  which  is  9000. 
The  salts,  and  especially  the  soluble  ones,  have 
been  found  from  one  fourth,  to  one  half  less  than 
their  usual  proportions.  The  colouring  matter  has 
been  found  to  have  increased  in  som*e  instances 
to  eight  or  ten  per  cent.  This  blood,  when  drawn 
from  the  patient,  appeared  like  the  dregs  taken 
from  a  cask  of  old  port,  of  a  muddy  purple." 

A  fact  worthy  of  remark  is,  that  those  who  have 
long  suffered  from  the  premonitory  symptoms, 
have  lost  both  the  water  and  salts  of  the  blood  in 
proportion  to  the  profuseness  of  the  evacuation  ; 
which  renders  it  probable  that  the  loss  of  water 
and  salts  from  the  fluids  of  the  system  would 
occur  from  any  profuse  evacuation. 

The  principles  of  the  blood  which  have  been 
lost,  have  been  found  both  in  the  evacuations  and 
the  perspirable  matter. 

Very  respectfully,  (fee. 

P.  S.*  It  has  been  contended,  that  a  critical 
reference  to  food  produces  a  morbid  sensitiveness 
on  that  subject,  and  that  this  fearful  apprehension 
is  likely  to  impair  still  more  the  healthy  tone  of 
the  stomach.  The  argument,  however,  is  not 
sustained  by  the  facts.  It  is  fear  which  impels  us 
to  an  observance  of  food  and  to  avoid  the  exciting 
causes.    When  public  attention  is  properly  di- 

5 


34 


reeled  to  this  subject,  and  the  exciting  causes  are 
well  understood,  the  fears,  which  agitated  the 
individual,  are  allayed,  and  he  eats  his  food  with 
a  conviction  of  its  inofFensiveness.  This  is  con- 
clusively shown  by  the  almost  universal  exemption 
from  cholera  of  such  as  are  properly  abstemious  ; 
and  I  have  had  the  most  ample  demonstration 
that  the  victims  to  this  disease,  among  the  sober 
members  of  society,  have  been  such  as  have  dis- 
regarded the  admonitions  of  experience  in  rela- 
tion to  food. — An  attempt  at  concealment  is  na- 
tural enough,  where  the  sufferer  has  been  in  some 
measure  the  victim  of  his  own  imprudence  ;  but  I 
think  that  society  requires  the  benefit  of  every  il- 
lustration of  this  subject,  and  I  do  not  hesitate  to 
declare  my  conviction,  that  in  most  instances  the 
disease,  in  this  city,  has  been  the  direct  result  or 
aome  error  on  the  part  of  the  individual. 


35 


LETTER  IV. 


New-Yobk,  August  22,  1832. 

Dear  Sir, 

A  FEW  days  ago,  in  replying  to  your  letter, 
I  did  myself  the  honour  to  state  to  you  the  re- 
sults of  my  own  observation,  and  that  of  others 
in  whom  I  have  particular  confidence,  in  the 
treatment  of  the  "  premonitory  symptoms"  of 
Cholera  Asphyxia,  These  symptoms  continue  to 
announce  the  approach  of  the  more  malignant 
stage,  with  rare  exceptions,  and  are  still  susceptible 
of  easy  removal.  Positive  injunctions  must  be 
given  to  the  patient,  to  deter  him  from  injurious 
indulgences  during  his  convalescence,  a  propen- 
sity to  which,  I  have  had  occasion  to  remark,  is  a 
characteristic  symptom,  and  which  frequently  in- 
volves the  sufferer  in  a  most  abrupt  transition  to 
the  fatal  stage  of  collapse.  To  effect  an  obser- 
vance of  the  proper  objects  of  attention,  it  is  not 
unfrequently  necessary  to  excite  the  fears  of  the 
individual. 

I  adverted  in  a  former  letter  so  very  briefly  to 
the  treatment  of  the  cholera  in  its  advanced  stages, 
and  as  the  disease  has  not  yet  presented  itself  to 
your  observation,  I  have  determined  to  avail  my- 
self of  a  few  moments  of  leisure,  to  submit  to  you 


36 


the  experience  of  the  best  physicians  in  this  city. 
There  was,  at  the  irruption  of  the  epidemic,  a 
greater  diversity  of  practice  than  prevails  at  the 
present  time.  The  fatality  of  the  disease,  and  the 
different  views  which  were  entertained  of  its  proxi- 
mate ctiuse,  necessarily  suggested  many  remedial 
agents  of  conflicting  principles,  and  every  subor- 
dinate expedient  that  ingenuity  could  devise.  I 
always  commended  this  enterprise  and  resource 
of  the  profession,  although  it  was  sometimes  op- 
posed to  my  own  prepossessions.  The  experience 
of  foreign  practitioners  was  only  conclusive  as  it 
related  to  the  epidemic  in  their  own  climates.  It 
had  here  invaded  almost  another  world,  and  it  was 
fair  to  presume,  that  its  character  would  be  modi- 
fied by  the  great  physical  differences  of  climate, 
and  a  thousand  local  accidents.  It  was  a  just 
presumption,  that  what  was  true  of  one  remedy  in 
Asia,  and  of  another  in  Europe,  might  be  found 
inapplicable  to  the  modified  disease  in  America. 
There  was,  and  is,  nothing  settled  in  regard  to 
the  proximate  cause,  and,  therefore,  we  could  de- 
rive butlittle  assistance  from  established  principles. 
Our  only  guide  was  existing  experience,  and  our 
only  hope,  in  the  favourable  direction  that  might 
be  given  to  experiment  by  modifying  circum- 
stances. Each  practitioner,  therefore,  met  the 
destroyer  with  such  weapons  as  experience  had 
provided,  or  his  own  ingenuity  suggested.  Their 
incongruity  was  certainly  indicative  of  the  unde- 
termined nature  of  the  disease  and  of  its  great 
fatality     Each  system  of  practice,  and  almost 


37 


every  remedy  employed,  have  been  fully  and  fairly 
applied  ;  and  after  a  careful  observation  of  their 
results,  I  am  prepared  to  say  that  we  have  gained 
nothing  since  the  disease  invaded  Europe.  It  is 
the  same  disease  here  as  it  was  in  Asia, — but  little 
modified  by  those  great  physical  causes  which  dis- 
tinguish the  different  climates  of  the  earth,  and 
which  not  only  generate  peculiar  diseases,  but 
exert  the  most  sensible  influence  on  the  moral  and 
physical  condition  of  man.  If  less  distinguished 
as  a  specific  disease  than  those  of  the  great  con- 
tagious family,  it  is  certainly  not  less  remarkable 
in  the  uniformity  of  its  phenomena ;  and  it  is 
almost  equally  characterized  by  pathognomonic 
symptoms.  This  identity,  also,  is  further  illus- 
trated by  the  coincidence  in  the  results  of  our 
treatment,  and  that  which  has  been  applied  in 
other  parts  of  the  globe.  From  this  rule,  how- 
ever, must  be  excepted  the  very  important  remedy 
of  blood-letting,  which  was  found  so  beneficial  in 
the  Indies  ;  but  even  to  this  we  have  not  given 
that  full  opportunity,  on  which  the  Anglo-Asiatic 
physicians  insisted — having  either  been  bafiled  in 
our  attempt  at  its  abstraction,  or  we  have  not  car- 
ried its  effect  beyond  that  deliquium  which  results 
from  the  removal  of  some  dozen  or  fourteen  ounces, 
and  beyond  whichj  we  are  told,  we  shall  reach  the 
great  centre  of  the  circulation,  and  re-action  com- 
mences. Although  the  moderate  depletion  by  this 
remedy,  which  has  been  often  practised  by  judi- 
cious hands  in  this  city,  has  seldom  encouraged 
any  hope  of  success,  I  am  determined  to  employ 


38 


it,  in  extenso,  when  favourable  opportunities  may 
occur.  I  will  confine  it  to  those  cases  in  which 
any  experiment  may  be  justified,  and  where  the 
diarrhoea  has  not  been  profuse.  The  arteries  will 
supply  us  with  any  quantity, — and  I  know  not  that 
25  or  30  ounces  of  blood,  so  obtained,  can  more 
endanger  the  patient,  than  an  exudation  of  200  or 
400  ounces  of  serum  from  the  mucous  membrane  of 
the  intestines.  The  disease,  however,  is  now  hap- 
pily passing  from  this  city,  and  should  you  be  so 
ill-fated  as  to  sufier  a  visitation,  I  shall  look  to 
you  for  a  decision  of  this  most  important  inquiry. 

I  entertain  no  doubt,  that  the  greater  suc- 
cess of  this  remedy  in  the  hands  of  the  Anglo- 
Asiatics  is  to  be  ascribed  to  the  absence  of  pre- 
monitory diarrhoea  in  the  East,  and  the  retention 
of  the  fluids  in  the  system  when  blood-letting  was 
so  usefully  practised.  It  is  equally  apparent,  also, 
that  we  may  depend  on  a  greater  probability  of 
success,  should  we  be  so  fortunate  as  to  meet  with 
the  blood  not  already  deprived  of  its  serum. 

In  regard  to  calomel^  my  own  experience  is 
sustained  by  that  of  our  best  physicians.  From 
the  particular  irritability  of  the  mucous  mem- 
brane, and  the  profuseness  of  the  discharges,  the 
prepossessions  of  many  physicians,  who  now  re- 
gard it  with  a  sense  of  dependence,  were  adverse 
to  its  exhibition.  The  little  encouragement, 
however,  which  they  derived  from  other  remedial 
agents,  directed  their  attention  to  the  declaration 
of  foreign  physicians,  that  this  medicine  not  only 
allays  the  irritability  of  the  mucous  membrane, 


39 


but  induces  that  change  of  action  which  is  neces- 
sary to  the  re-establishment  of  health.    I  may 
safely  assure  you,  Sir,  that  our  best  practitioners 
now  employ  calomel  in  doses  of  10  to  30  grains, 
with  more  confidence  than  they  repose  in  all  other 
remedies.    Either  with  or  without  small  quanti- 
ties of  opium  and  camphor,  according  to  the  ex- 
isting state  of  the  serous  evacuations,  it  seldom 
fails  to  allay  the  irritability  of  the  mucous  mem- 
brane, and  of  the  system  generally  ;  to  mitigate 
or  remove  the  spasms  ;  and  if  the  case  be  suscep- 
tible of  relief,  to  convert  the  discharges  from  the 
appearance  of  rice  water  to  that  of  the  green  con- 
fervae,  or  the  not  infrequent  blackness  and  consist- 
ence of  boiling  tar.    This  transition  is  nearly  a 
sure  omen  of  a  radical  chancre  throuorh  the  whole 
system.    Then  are  we  delighted  with  an  almost 
simultaneous  developement  of  the  great  functions 
of  life.    The  action  of  the  heart  is  no  longer 
almost  extinct;  we  press  the  arteries  with  a  thrill- 
ing sense  that  Death  himself  is  subdued  ;  we  are 
warmed  into  hope  and  joy  by  the  returning  heat 
to  the  extremities  ;  the  hand  no  longer  burns  on 
the  region  of  the  epigastrium,  where  the  heat  may 
have  borne  a  contrast  at  106  degrees;  the  features 
begin  to  expand,  and  the  prophetic  blueness  to 
fade  away  into  the  flush  of  life  or  the  vermilion 
of  a  less  dangerous  congestion ;  and  although  a 
spectacle,  rare  in  opposition  to  others  that  have 
baffled  the  same  skill  and  the  same  physical  means, 
we  contemplate  the  result  even  with  admiration,  so 
great  is  the  victory,  and  so  obvious  the  triumph  of 
art. 


40 


Although  calomel  thus  transcends  all  other  re- 
sources in  the  treatment  of  Asphyxiated  Cholera, 
there  are  subordinate  agents  of  indispensable  im- 
portance. These  consist  chiefly  of  all  those  means, 
which,  applied  externally,  stimulate  the  skin  and 
excite  the  vascular  action  of  that  organ.  Heat  is 
the  most  important,  and  is  commonly  applied  by 
accumulating  around  the  patient  bottles  of  boiling 
water,  bags  of  hot  sand,  the  air  bath,  &c.  Hot 
chalk  is  an  excellent  application  when  the  skin  is 
wet  with  perspiration.  Stimulants  of  every  kind 
have  been  employed,  and  none  more  universally 
than  mustard  cataplasms  to  the  extremities  and 
abdomen.  It  is  my  practice  to  apply  a  very  large 
blister  over  the  abdominal  region,  as  soon  as  there 
is  the  least  probability  of  its  making'any  impression. 
An  ointment  has  been  introduced  at  the  Green- 
wich Hospital  by  its  intelligent  and  ingenious 
physician.  Dr.  Roe,  and  adopted  with  evident 
benefit  at  other  hospitals  and  in  private  practice. 
It  consists  of  one  pound  of  strong  mercurial  oint- 
ment, seven  ounces  of  Cayenne  pepper  and  seven 
ounces  of  camphor,  intimately  blended.  The 
whole  surface  of  the  patient  is  thoroughly  rubbed* 
with  this  composition,  by  means  of  a  brush,  and 
the  process  frequently  repeated  till  reaction  en- 
sues, or  salivation  is  effected.  Another  ointment 
has  been  compounded  by  Dr.  Rhinelander,  of  the 
Crosby-street  Hospital,  and  is  prepared  in  the 
following  manner  :  Take  of  red  pepper  and  cam- 
phor each  half  a  pound,  simple  ointment  one 
pound,  muriatic  acid  one  ounce.    Triturate  to- 


41 


gether  the  powdered  camphor  and  pepper,  adding 
the  acid.    Pour  the  mixture  into  the  melted  oint- 
ment, carefully  stirring  it.    The  ointment  is  very 
freely  applied  to  the  whole  surface,  and  the  skin 
afterwards  covered  with  hot  chalk.    In  this  pre- 
paration, the  active  principle  of  the  pepper  is 
evolved  by  the  acid,  and  it  possesses,  therefore,  the 
advantage  of  being  more  stimulating  than  the 
other,  but  it  wants  the  specific  property  which  is 
imparted  by  the  mercury.    Dr.  Roe's  prescription 
is  found  an  excellent  adjuvant,  in  co-operation 
with  calomel,  in  producing  the  constitutional  effect 
of  that  substance,  and,  with  proper  subsequent 
treatment,  a  patient  is  rarely  lost  after  salivation 
is  established.   Various  other  stimulants,  more  or 
less  compounded,  are  in  use,  and  are  all  found 
preferable  to  dry  friction. 

The  hot  hath  has  not  been  much  employed, 
and  has  been  considered  inferior  to  the  other 
means  of  applying  heat.  I  once  assisted  some 
medical  friends,  in  immersing  a  patient,  whose 
case  presented  all  the  striking  phenomena  that 
are  described  by  the  oriental  physicians,  in  a  bath 
in  which  was  diffused  a  pound  of  strong  flour  of 
mustard.  I  have  seen  no  case  since,  terminating 
fatally  in  so  short  a  time,  in  which  reaction  was 
more  fully  effected,  and  I  have  not  since  repeated 
the  experiment.  Time  for  action  is  short,  and 
there  has  never  been  a  tub  or  water  at  hand. 
From  the  result  of  that  application,  although  the 
patient  died  soon  after,  I  think  the  mustard  bath 
is  worthy  of  further  triaL  Dry  heat  by  means  of 

6 


42 


burning  alcohol  has  been  fully  applied,  but  with 
no  very  useful  effect. 

I  have  been  long  in  the  habit  of  employing  ice 
for  the  relief  of  vomiting,  and  it  is  found  essen- 
tially useful  for  the  same  purpose  in  Cholera  As- 
phyxia. It  also  allays  the  thirst,  and  thus  removes 
one  great  cause  of  restlessness.  How  far  it  ex- 
erts an  impression  on  the  morbid  action  is  a  sub- 
ject of  inquiry.  An  extraordinary  degree  of  heat 
is  evolved  about  the  region  of  the  stomach.  In 
one  case,  in  which  I  applied  the  thermometer  to 
the  surface,  a  temperature  of  about  106  degrees 
was  denoted  while  the  patient  was  expiring.  I 
have  imagined  that  these  cases  will  be  more  gene- 
rally benefited  by  the  external  application  of  ice 
to  the  epigastric  region,  than  by  mustard  cata- 
plasms. Ice,  too,  I  have  applied  advantageously  to 
the  head  in  obvious  congestions  of  the  brain,  which 
are  frequently  attendant  on  Cholera,  or  arise  as 
one  of  its  consecutive  diseases.  It  is  also  very 
advantageously  applied,  for  the  relief  of  spasm, 
to  the  muscles  affected. 

Stimulants,  internally,  have  been  almost  unani- 
mously employed,  and  by  some  to  a  very  great- 
extent.  We  have  seen  but  little  benefit  arising 
from  them,  and  least  of  all  from  opium  given  as 
a  stimulant.  I  think  the  Cholera  has  conclusively 
shown  that  its  mode  of  action  is  sui  generis^  and 
not  analogous  to  that  of  alcohol.  In  very  mode- 
rate doses,  it  is  useful  in  allaying  the  irritable  state 
of  the  mucous  membrane,  particularly  in  restrain- 
ing the  evacuation*  ;  but,  beyond  this  purpose,  I 


43 


believe  it  never  fails  to  do  harm.  The  best  of  the 
profession,  and  who  have  seen  most  of  the  disease 
employ  alcoholic  stimulants  in  great  moderation, 
and  generally  prefer  the  more  volatile  and  diffu- 
sible. Their  use  is  clearly  suggested  by  the  fail- 
ing powers  of  life ;  by  the  very  languid  state  of 
the  circulation,  and  other  phenomena  incident  to 
approaching  dissolution.  But,  in  opposition  to 
these  symptoms,  they  are  contradicted  by  the 
pathology  of  the  disease, — at  least  by  some  of  its 
local  developements.  We  have  seen  no  benefit 
from  their  liberal  use,  and  it  is  even  doubtful  whe- 
ther they  contribute  much  in  any  quantities.  It 
requires  the  conviction  of  experience,  however,  to 
enable  us  to  abstain  from  their  use,  and  to  resist 
the  impulse  to  apply  them  to  the  dying  spark. 

One  of  the  best  properties  of  these  agents  is 
that  of  allaying  nausea  and  vomiting,  particular- 
ly diluted  brandy.  Dr.  Arnoldi,  of  Montreal,  in- 
forms me  that  he  employed  with  great  success 
small  quantities  of  brandy  and  strong  coffee  in 
combination  ;  but  I  have  never  tried  it. 

Emetics  have  not  been  the  subject  of  much  ex- 
periment. Experience  in  the  old  world  has  ad- 
monished us  of  their  danger  ;  pathology  is  op- 
posed to  their  exhibition  ;  and  the  alarming  ir- 
ritability of  the  mucous  membrane,  and  the  ter- 
rific prostration  of  the  vital  powers,  have  de- 
terred us  from  their  use.  We  have  hastened  to 
quiet  the  tumult  by  more  sedative  or  by  exciting 
means  of  another  character.  Where  they  have 
been  employed  in  Asphyxiated  Cholera,  I  think 


44 


I  am  warranted  in  saying  they  have  hastened  the 
fatal  termination.  Where  they  have  been  em- 
ployed with  success,  I  have  no  doubt  it  has  been 
in  what  is  regarded  as  the  forming  stage  of  the 
disease. 

In  the  progress  of  convalescence,  emetics  are 
occasionally  salutary,  but  it  is  only  after  an  ab- 
solute impression  has  been  made  on  the  morbid 
action.  It  has  been  very  judiciously  observed 
by  a  committee  deputed  by  the  Kappa  Lambda 
Association,  in  their  publication  on  this  disease, 
that,  after  the  system  begins  to  react,  and  the 
calomel  to  operate,  there  is  a  discharge  of  im- 
mense quantities  of  dark  porraceous  bile,  like 
boiled  spinage,  and  this  often  collects  about  the 
praecordia,  creating  great  distress,  even  so  as  to 
prevent  the  patient  from  lying  on  either  side. 
This  very  troublesome  symptom  has  been  found 
to  yield  immediately  to  the  operation  of  an  eme- 
tic of  warm  salt  water,  or  of  Seidlitz  powders  re- 
peated at  intervals."  The  result  of  the  observa- 
tion of  the  committee  is  of  course  correct,  al- 
though I  think  the  philosophy  wrong. 

Cathartics.  I  have  not  placed  calomel  in  con- 
nexion with  this  class  of  remedies,  as  its  supe- 
rior advantages  in  Cholera  depend  on  its  speci- 
fic mode  of  action.  Its  ultimate  operation  as  a 
cathartic  is  doubtless  desirable,  but  not  essential 
to  the  changes  it  exerts.  When  we  have  accom- 
plished all  that  we  contemplated  in  the  prelimi- 
nary treatment  of  Asphyxia  by  this  remedy,  and 
a  cathartic  is  indicated,  none  answer  so  good  a 


45 


purpose  as  castor  oil.  I  have  long  been  satisfied, 
though  I  do  not  recollect  to  have  heard  or  to  have 
seen  the  remark,  that  castor  oil  exerts  a  specific 
action  on  the  liver,  and  sustains  a  rank,  in  that  rela- 
tion, only  subordinate  to  the  mercurial  prepara- 
tions. It  manifestly  co-operates  with  the  latter  in 
the  production  of  bilious  discharges,  and  will,  in- 
dependently, produce  that  result  more  than  any 
other  cathartic.  It  possesses,  also,  the  eminent 
advantage  of  generally  irritating  less  the  mucous 
membrane,  or  prostrating  the  strength.  Dr. 
Caldwell,  of  JMontreal,  informs  me  in  a  letter  to 
Professor  M'Naughton  and  myself,  that  he  em- 
ployed as  a  cathartic,  after  the  exhibition  of  calo- 
mel in  the  earlier  stages  of  this  disease,  tart, 
potassse  3ij.  in  a  little  warm  chicken  broth, 
which  he  repeated  every  second  hour  until  it 
operated  freely.  Nothing,"  says  that  eminent 
gentleman,  seemed  to  allay  the  gastric  irritation 
so  well  as  the  soluble  tartar.  In  many  instances 
it  seemed  to  act  as  a  charm,  and  I  do  not  know 
a  single  instance  of  any  one,  who  went  through 
the  influence  of  this  treatment,  that  was  subse- 
quently attacked  with  Cholera,"  In  the  progress 
of  the  case,  rhubarb  and  magnesia,  especially 
when  combined  with  more  than  an  equal  quanti- 
ty of  Rochelle  salts,  answers  a  good  purpose. 
The  salts,  probably,  by  accelerating  the  opera- 
tion, prevents  the  rhubarb  from  irritating  the 
mucous  membrane.  The  common  saline  cathar- 
tics, uncombined,  irritate  the  bowels,  and  are  ge- 
nerally prejudicial.    I  know  but  little  of  the  ac- 


4G 


tion  of  the  resinous,  not  having  employed  them 
from  their  irritating  properties.  I  have  seen  As- 
phyxia produced  by  their  severe  operation.  An- 
nesley  often  combined  aloes  v^^ith  his  scruple 
doses  of  calomel  to  effect  more  perfectly  the  eva- 
cuation of  the  pultaceous  creamy  matter,  which 
often  filled  the  intestines,  and  to  the  presence  of 
which  he  ascribed  so  much  evil.  We  do  not  find 
this  an  attendant  symptom,  to  any  great  extent, 
of  our  choleric  patients.  I  think  also  that  an  ob- 
jection applies  to  the  irritating  properties  of  sen- 
na, and  I  believe  it  is  very  rarely  used.  Char- 
coal is  given  by  a  few  as  an  adjuvant  to  other 
cathartics.  This  class  of  remedies  is  clearly 
only  indicated  after  a  considerable  change  in  the 
morbid  action  has  been  effected  by  other  agents. 

Camphor  has  had  in  New  York  its  few  warm 
and  respectable  advocates  ;  but  the  great  pro- 
portion of  the  profession  have  not  the  least  confi- 
dence in  its  remedial  properties.  Its  cause  has 
not  been  sustained  by  any  authenticated  cases,  and 
when  employed  alone,  it  has  been  perfectly  abor- 
tive in  my  own  hands.  It  is  directed  to  be  exhi- 
bited in  doses  of  three  to  five  drops  of  the  saturated 
tincture,  frequently  repeated  ;  and  to  be  employ- 
ed, at  the  same  time  and  in  larger  quantities,  in 
the  form  of  enemata.  It  is  very  useful  in  allay- 
ing some  of  the  symptoms  of  the  "  precursory 
stage,"  and  is  an  excellent  adjuvant  in  subduing 
the  irritability  of  the  stomach  and  bowels,  and 
controlling  the  spasms  in  the  advanced  stage  of 
Asphyxia.    For  this  latter  purpose,  also,  it  exerts 


47 


a  good  effect  when  applied  externally.  It  imparts 
to  opium  a  more  sedative  effect,  and  forms  with 
that  substance  and  calomel  an  admirable  combi- 
nation when  vomiting  and  diarrhoea  exist.  It  is 
liable  in  large  doses  to  produce  determination 
to  the  brain.  When  employed  as  a  specific,  its 
exhibition  proceeds  on  the  homopathic  plan. 

Opium  and  its  preparations.  I  have  briefly  ad- 
verted to  this  substance  as  employed  by  some 
physicians  with  a  reference  to  its  supposed  stimu- 
lating properties,  and  have  explained  the  general 
result  in  the  use  of  it.  When  given  in  excess,  it 
seldom  fails  to  aggravate  all  the  phenomena  of 
congestion,  and  has  done  more  mischief  in  the 
premonitory  stages.  It  is  valuable  when  cau- 
tiously employed,  and  it  not  unfrequently  happens 
that  one  preparation  is  preferable  to  another.  In  a 
former  letter,  I  indicated  some  of  the  conditions 
of  the  premonitory  stage  in  which  it  was  evident 
that  the  camphorated  tincture  was  best.  Dr. 
Tappan,  of  the  Park  Hospital,  informs  me  that  he 
exhibits  with  the  first  dose  of  calomel  about  ten 
grains  of  Dover's  powder  with  a  happy  effect ;  and 
I  may  here  remark  that  it  is  frequently  his  practice, 
after  the  plan  of  some  Anglo-Asiatics,  to  adminis- 
ter a  full  dose  of  opium  immediately  after  blood- 
letting in  the  less  advanced  stages  of  the  disease  ; 
a  practice  which  is  sustained  by  the  report  of  the 
Kappa  Lambda  Association.  I  have  found  in  the 
sulphate  of  morphine,  a  preparation,  least  of  all 
liable  to  objection.  Its  astringency  is  not  suffi- 
ciently great  to  arrest  any  profuse  diarrhoea ;  but 


48 


where  it  is  chiefly  an  object  to  allay  the  irritability 
of  the  stomach,  to  subdue  the  spasms,  and  to  tran- 
quillize the  system,  its  effect  is  admirable,  and  its 
tendency  to  increase  congestion  comparatively  lit- 
tle.When  purging  and  vomiting  exist  in  connexion 
to  any  great  extent,  it  is  useful  to  give  the  sulphate 
of  morphine,  and  to  administer  the  tincture  of 
opium  by  injections.   The  sulphate  of  quinine  has 
been  employed  in  a  few  cases  at  the  Crosby-street 
Hospital,  with  and  without  calomel,  in  doses  of 
ten  grains,  once  in  an  hour  or  two.    The  effect 
has  been  uniformly  rather  bad,  and  the  patients 
have  died.    Charcoal  has  been  employed  by  a 
few  physicians,  and  is  in  still  greater  repute  as  a 
popular  remedy.   By  the  latter  class,  it  is  of  course 
only  exhibited  in  the  mild  stages  of  the  disease  ; 
and  when  any  apparent  benefit  has  arisen  from  it, 
the  subjects,  I  believe,  in  all  instances,  have  only 
been  affected  with  the  premonitory  symptoms.  It 
certainly  can  exert  no  effect  on  the  vital  proper- 
ties, and,  of  course,  does  not  reach  the  functions 
through  the  only  media  by  which  such  a  disease 
can  be  subverted.    Its  action  is  evidently  merely 
chemical,  as  an  absorbent,  and  laxative  by  its 
mechanical  irritation. 

Injections  are  very  subordinate  remedies,  and 
have  been  most  advantageous  when  employed 
to  impart  heat  to  the  intestines  through  the  me- 
dium of  water,  or  restrain  evacuations  by  the 
agency  of  opium.  Large  quantities  of  hot  water 
have  been  sometimes  absorbed  in  an  hour  or  two, 
after  being  injected.    At  other  times  it  has  been 


49 


removed,  at  a  very  reduced  temperature,  without 
any  sensible  diminution  of  its  quantity.  This  is 
probably  a  better  mode  of  administering  alcoholic 
stimulants,  than  by  the  mouth.  The  weight  of 
experience  here  is  more  in  favour  of  this  method. 
When  vomiting  does  not  exist  in  connexion  with 
diarrhoea,  it  is  also  better  to  restrain  the  latter  by 
injections  of  laudanum,  than  to  introduce  much 
opium  into  the  stomach.  Composed  of  warm 
water,  they  are  useful  auxiliaries  in  the  progress 
of  convalescence,  to  relieve  the  tormina  which 
sometimes  proceeds  from  the  irritation  of  the  acrid 
bile.  An  infusion  of  tobacco,  according  to  the 
suggestions  of  Mr.  Baird,  was  kindly  injected  at 
my  request,  in  one  or  two  cases  at  the  Crosby- 
street  Hospital,  but  evidently  with  a  bad  effect. 
Other  gentlemen  have  informed  me  that  they  have 
derived  no  benefit  from  its  use.  A  solution  of  the 
super  sulphate  of  alumen  was  freely  administered 
per  anum  et  per  orem,  at  the  Bellevue  Hospital, 
where  it  was  used  on  the  principle  of  its  astrin- 
gency  ;  but  I  believe  the  very  enterprising  gentle- 
men of  that  institution  were  disappointed  in  its  effect. 

Cupping  and  leeching  have  had  a  full  propor- 
tion of  our  attention.  They  are  less  salutary 
than  general  blood-letting,  when  it  is  an  object 
to  produce  an  impression  on  the  whole  system, 
or  for  the  relief  of  high  vascular  action,  whether 
local  or  general.  In  Asphyxiated  Cholera,  where 
there  exists  more  than  the  usual  determination 
of  blood  to  the  head,  they  have  been  found  use- 
ful, and  contribute  to  the  relief  of  oppression  at 
•  7 


50 


the  precordia,  and  some  of  the  varieties  of  ab- 
dominal distress.  Like  general  blood-letting, 
the  local  abstraction  is  often  indispensable,  in 
the  treatment  of  some  of  the  consecutive  diseases. 

Transfusion,  according  to  Dr.  Latta's  me- 
thod, has  been  tried,  and  found  wanting.    It  has 
been  employed  in  numerous  instances  at  the 
hospitals,  and  in  private  practice.    T  have  in- 
jected but  one  patient,  who  was  surprisingly  be- 
nefited for  a  short  period,  but  who  soon  relapsed  in- 
to his  dying  condition,  and  expired  in  three  hours 
after  the  operation.    The  results  of  this  experi- 
ment have  been  generally  uniform.    The  circu- 
lation is  re-established,  and  sometimes  with  con- 
siderable vigour  ;  the  temperature  of  the  body  is 
universally  augmented  ;  the  cold  perspiration  is 
converted  to  an  animating  warmth  ;  the  oppress- 
ed respiration  is  removed  or  relieved  ;  the  livid 
hue  of  the  features  is  changed  to  the  flush  of 
health  ;  the  general  restlessness  is  subdued  ;  and 
the  patient  exclaims  that  his  cure  is  almost  com- 
pleted.   I  witnessed  an  interesting  exemplifica- 
tion of  these  phenomena,  in  a  very  robust  sub- 
ject, at  the  Crosby-street  Hospital,  who  was  suf- 
fering the  whole  array  of  symptoms  that  distin- 
guish the  collapsed  Cholera.     The  operation 
was  performed  by  Dr.  Depeyre,  and  the  solution 
injected  stood  at  the  temperature  of  1 14  degrees. 
A  thermometer  was  introduced  within  his  mouth, 
and  the  temperature  marked  at93degrees.  Three 
pounds  were  slowly  transfused,  and  the  thermo- 
meter had  risen  to  lOlJ  degrees.    All  the  evi- 
dent improvement  I  have  noticed  above  imme- 


51 


diately  ensued,  and  the  man  laughed  aloud  from 
the  ecstacy  of  relief.  This  man  was  a  corpse  an 
hour  after.  These  results  embarrass  the  hypothe- 
sis of  the  humoral  pathologists,  and  supply  ano- 
ther argument  to  those  who  assign  the  proximate 
cause  to  a  modification  of  the  properties  and 
functions  of  organic  life,  and  who  regard  the  al- 
teration of  the  blood  and  the  other  fluids  as  con- 
secutive, and  only  one  of  the  numerous  symptoms 
which  arise  from  morbid  action. 

I  can  only  learn  that  "  Dr.  Leo's  Method"  has 
been  tried  at  the  Greenwich  Hospital,  notwith- 
standing its  claim  of  novelty,  and  the  well-known 
properties  of  his  remedy.  It  was  found  wholly 
inert. 

Electricity  has  received  but  an  unsatisfactory 
trial,  though  I  am  informed  that  it  has  produced 
no  sensible  effect. 

The  hypothetical  treatment  of  Dr.  Binaghi  has 
been  put  to  the  test,  especially  at  the  Crosby- 
street  Hospital,  and  has  added  another  demon- 
stration of  the  inefficiency  of  remedies  that  are 
directed  to  the  primary  impression  of  a  mor- 
bific poison,  acting,  by  concession,  through  the 
medium  of  the  nervous  sy stein,  but  having  in- 
volved every  other  tissue,  and  deranged  the  whole 
economy  of  organic  life.  The  moxa,  burning  al- 
cohol, et  id  omne  genus,  having  had  their  day, 
no  longer  torture  our  patients  in  vain.  The  sul- 
phate of  quinine,  I  have  said,  has  been  also  in- 
sufficient in  the  few  instances  in  which  it  has 
been  given  ;  but  as  to  strychnine,  brucine,  &.c. 
commended  by  this  writer  and  Haaz,  I  cannot 


52 


learn  that  they  have  received  any  notice  ;  nor  do  I 
know  that  hyosciamus  and  cicuta  have  been  ap- 
plied as  remedial  agents. 

The  oxygene  and  7iitrous  oxide  gases  have 
been  tried  at  the  Greenwich  and  other  hospitals  ; 
but  I  am  informed  by  the  gentlemen  connected 
with  three  of  those  institutions,  that  they  have 
obtained  no  benefit  from  their  use, — and  that  the 
blueness  of  the  skin  was  not  even  influenced. 

A  negative  part  of  the  treatment,  of  very  great 
importance,  consists  in  the  exclusion  of  all  food, 
and  even  of  water, — so  necessary  is  it  to  subdue 
the  irritability  of  the  stomach,  and  so  easily  is  that 
organ  offended. 

I  had  intended,  when  I  began  this  letter,  to  have 
illustrated  our  practice  by  its  application  to  par- 
ticular modifications  of  the  disease.  There  are 
very  few  who  have  any  confidence  in  the  specific 
action  of  any  remedy ;  and  that  treatment  can 
only  be  successful  which  is  determined  by  general 
principles,  and  the  peculiarities  of  each  individual 
case.  Th^  best  indications  are  frequently  derived 
from  idiosyncrasies,  and  where  these  are  neglected 
the  greatest  advantages  are  lost.  I  have  no  doubt 
that  it  is  owing  much  to  this  circumstance,  that 
blood-letting  has  so  constantly  failed  at  our  hos- 
pitals, where  the  subjects  are  broken  down  by 
intemperance,  or  by  previous  disease.  Too  much 
praise,  however,  cannot  be  given  to  those  gentle- 
men who  have  employed  a  remedy  so  philosophi- 
cal, and  yet  so  opposed  to  prejudice,  when  it  was 
obvious  that  empyrical  practice,  or  even  the  power 


53 


of  calomel,  must  fail.  Since  my  preceding  ob- 
servations on  the  subject  of  blood-letting,  I  have 
been  informed  by  Dr.  Dekay,  that,  in  his  private 
practice  he  has  adopted  this  remedy,  with  the  best 
success  in  very  advanced  stages  of  the  disease, 
when  the  constitution  of  the  subject  was  adequate 
to  a  co-operation  with  art.  This  gentleman  ex- 
hibits diffusible  stimulants  freely  at  the  same  time, 
with  large  doses  of  opium,  which  he  regards  as 
essential  to  the  success  of  blood-letting.  He  has 
not  observed  any  deleterious  effect  from  the 
opium,  and  its  tendency  to  produce  congestion 
is  counteracted  by  the  impression  from  the  ab- 
straction of  blood. 


Very  respectfully,  &c. 


54 


LETTER  V. 


New- York,  August  26th,  1832. 

Dear  Sir, 

Having  hitherto  restricted  my  letters  to 
practical  remarks  on  the  Cholera  of  New- York, 
I  shall  venture  to  digress  from  experience  to 
theory ;  although  I  do  not  imagine  that  you  can 
be  much  interested  by  any  communication,  which 
does  not  relate  to  the  important  facts  that  apper- 
tain to  this  subject.  Still,  the  propensity  to  spe- 
culate on  these  facts  becomes  irresistible  ;  and 
however  one  may,  at  first,  resolve  not  to  entan- 
gle himself  in  the  mazes  of  hypothesis,  he  un- 
avoidably arrives  at  principles  which  influence 
his  judgment,  and  which  finally  become  so  im- 
portant to  himself,  that  he  cannot  believe  that 
they  will  not  be  interesting  to  others. 

The  first  opinion  I  intend  to  examine  is  that 
which  places  the  proximate  cause  of  the  Spas- 
modic Cholera  in  the  bowels,  and  which  sup- 
poses injiammation  of  those  organs  to  be  the 
source  of  the  whole  mischief.  This  doctrine  is 
insidious,  and  derives  great  plausibility  from  the 
frequency  of  the  small  intestines  exhibiting  a 
pinkish  appearance, — from  the  occasional  soften- 


55 


ing  of  their  tunics, — from  the  vomiting  and  purg- 
ing,— and  from  its  being  capable  of  explaining 
many  of  the  morbid  changes  that  arise  in  other 
parts  of  the  system,  on  the  principle  of  sympathy. 
But  inflammation,  to  produce  such  extensive 
sympathies,  and  such  a  rapid  succession  of  phe- 
nomena, so  soon  resulting  in  death,  must  be 
severe.  Its  existence,  however,  is  scarcely  de- 
noted by  many  of  its  usual  characteristics.  There 
is  never  any  hardness  of  the  pulse,  no  cupping  of 
the  blood,  and  scarcely  a  pelicle  of  coagulable 
lymph, — abstracted  with  whatever  care, — no  ten- 
derness of  the  abdomen  and  no  continued  pain, 
no  remarkable  prostration  of  the  muscular 
strength,  no  dryness  and  no  redness  of  the  tongue 
or  fauces,  and  no  symptomatic  fever.  Pathologi- 
cal anatomy  is  scarcely  less  conclusive  against 
this  theory.  Our  own  necroscopic  researches 
correspond  with  the  observations  that  have  been 
made  in  the  other  hemisphere.  We  look  in  vain 
for  that  florid  redness  which  distinguishes  acute 
inflammation.  Its  hue  is  dull,  nor  does  it  exist  in 
those  minute  vessels  which  are  the  instruments 
of  that  mode  of  disease.  It  is  evident,  that  this 
appearance  exists  in  the  venous  and  not  in  the 
arterial  system.  The  larger  arteries,  leading  to 
the  intestines,  are  exhausted  of  blood;  the  veins 
are  commonly  full,  and  there  is  never  presented 
any  of  that  minute  injection,  which  would  be  ne- 
cessary to  the  existing  condition  of  the  larger 
vessels,  did  the  redness  reside  in  the  terminating 
series  of  the  arterial  vessels.    But  this  redness 


56 


does  not  uniformly  belong  to  the  mucous,  and  may 
then  be  found  to  exist  in  the  serous  tissue  ;  as  was 
observed  in  the  case  of  the  black  female  which  I 
reported  on  the  2d  of  July,  and  which  is  noticed 
by  others.  The  constitution  of  these  tissues  is 
so  different,  and  the  ordinary  results  of  their 
morbid  affections  are  so  characteristic  of  their 
peculiarities,  that  striking  modifications  should 
at  least  arise,  when  inflammation  of  one  or  the 
other  might  happen  to  be  the  proximate  cause  of 
Asphyxiated  Cholera.  The  almost  constant 
pathognomonic  symptoms  of  this  disease,  the  very 
uniform  combination  of  more  accidental  pheno- 
mena, and  the  analogies  supplied  by  other  tissues 
of  the  system,  are  certainly  opposed  to  an  hypo- 
thesis which  ascribes  the  seat  of  the  inflammation, 
indiscriminately,  to  the  mucous  or  the  serous 
organs.  And  here  let  me  remark  an  important 
circumstance,  which  adds  to  the  obscurity  of  the 
subject.  Notwithstanding  the  redness  be  wholly 
confined  to  the  serous  tissue,  the  discharges  of 
serum  from  the  mucous  membrane  are  as  abun- 
dant, as  when  that  organ  is  the  seat  of  the  vascular 
fulness.  These  are  phenomena  which  require  in- 
vestigation. This  irregular  developement  of 
congestion,  and  sometimes  of  inflammation,  in  one 
or  the  other  of  these  coats  of  the  intestines,  will 
doubtless  account  for  the  tenderness  of  the  abdo- 
men in  some  instances,  and  for  its  absence  in 
most.  It  has,  however,  happened  in  many  in- 
stances, that  the  appearance  of  redness  is  wholly 
wanting,  and  we  are  then  told  that  the  nature  of 


57 

inflammation  is  not  understood,  and  that  redness 
is  not  necessary  to  its  existence.    Thus  driven 
from  the  most  difficult  entrenchment,  the  hyper- 
semia  of  Andral  is  preferred  by  some,  for  the 
still  greater  ambiguity  of  the  term,  and  its  more 
generic  import.    But,  yet  another  sign.  The 
mucous  tissue  is  softened, — it  is  disorganized, — 
and  therefore  is  denoted  the  most  active  inflam- 
mation.   When  v^as  it  proved,  I  would  inquire, 
that  no  other  mode  of  action  is  capable  of  pro- 
ducing such  a  change  ?  Who  ever,  before,  wit- 
nessed the  Cholera  Asphyxia  ?  and  may  there 
not  be  something  in  that  disease,  differing  even 
from  inflammation,  that  may  modify  or  derange 
the  structure  of  organs  1    What  action  is  that 
which  precedes  mortification  of  the  lower  ex- 
tremities in  subjects  of  an  advanced  age,  with- 
out any  apparent  exciting  cause,  or  any  sensible 
evidence  of  inflammation  ^    The  morbid  action 
of  Cholera  sometimes  tends  to  the  disorganiza- 
tion of  the  whole  body.    We  see  it  in  the  blood 
before  life  is  extinct, — we  recognise  the  wither- 
ing poison  in  the  frequent  flabbiness  of  the 
heart,- — and  we  are  sure,  from  the  rapid  decom- 
position of  the  body,  in  some  cases,  that  there 
had  been  almost  a  conflict  between  the  vital  pro- 
perties and  the  laws  of  chemistry. — I  will  not  il- 
lustrate these  phenomena  by  the  operation  of 
the  electric  fluid, — for  I  believe  that  they  arise 
not  alone  from  the  absolute  extinction  of  life,  but 
owe  much  of  their  production  to  the  elements  of 
disease.    This  argument,  however,  like  the  last, 

8 


58 


is  deficient  in  the  uniformity  of  facts.  The  soft- 
ening of  the  mucous  tissue  occurs  without  any 
other  sensible  mark  of  inflammation,  or  does  not 
exist  where  inflammation  may  be  obvious  ;  and 
in  a  majority  of  cases  it  does  not  occur.  It  is 
sometimes  seen,  and  again  is  absent  under  the 
most  similar  circumstances.  The  most  remark- 
able instance  I  have  witnessed  occurred  in  the 
black  female  to  whose  case  I  have  alluded,  and 
whose  disease  was  of  short  duration.  I  accident- 
ally omitted  the  fact  in  my  report  of  that  case, 
but  every  tissue  of  the  small  intestines  was  so 
softened,  that  they  were  easily  penetrated  by  my 
finger.  It  will  be  recollected  that  the  appear- 
ance of  congestion,  in  that  case,  was  confined  to 
the  serous  membrane.  It  is  said  that  the  glands 
of  Brunner  and  Peyer  are  enlarged,  and  that 
thus  this  particular  species  of  morbid  action  is 
denoted  ;  but  this  argument,  like  the  others, 
must  fall  from  want  of  the  fact.  I  have  known 
it  to  have  been  absent  in  at  least  an  equal  num- 
ber of  the  many  cases  which  I  have  seen  examin- 
ed, and  the  weight  of  the  best  authority  is  against 
it.  I  have  seen  these  enlargements  in  some  in- 
stances, the  evident  consequence  of  an  antece- 
dent chronic  diarrhoea. 

Perhaps  the  fallacy  of  this  doctrine,  which  I 
have  endeavoured  to  invalidate,  may  be  illustra- 
ted by  the  recital  of  a  single  case,  though  others 
analogous  are  constantly  occurring.  But  a  few 
days  since  I  was  summoned  in  the  morning  to 
attend  a  young  lady  who  had  been  attacked  in 


59 


the  night  with  malignant  Cholera.     She  had 
been  for  a  few  years  rather  delicate,  and  suscep- 
tible of  congestive  diseases  of  the  abdominal  vis- 
cera.   Since  the  irruption  of  the  epidemic,  she 
had  been  twice  affected  by  diarrhoea,  but  which 
spontaneously  subsided.    The  last  attack  was 
four  or  five  days  anterior  to  the  catastrophe  of 
which  I  am  speaking  ;  and  during  the  interve- 
ning period  all  was  quiescent.    I  entered  her 
chamber  at  fifteen  minutes  before  seven  o'clock, 
and  her  hyppocratic  countenance  expressed  but 
too  truly,  that  the  destroyer  had  almost  done  his 
work.     Her   case,  therefore,  may   be  briefly 
told.    She  had  felt  entirely  well  on  the  pre- 
ceding day,  and  up  to  the  hour  of  retiring  at 
twelve  o'clock.    She  had  eaten  for  her  dinner 
of  hashed-beef,  a  few  stringed  beans,  a  light 
mealy  potato  and   a  small  beet.     The  repast 
was  finished  with  baked  rice  pudding  and  a  sweet 
sauce.    I  believe,  however,  they  were  all  taken  in 
moderation.     At  her  tea  she  took  nothing  more 
than  toast.    Between  eleven  and  twelve,  prompt- 
ed by  a  good  appetite,  she  ate  again  of  the  cold 
pudding  and  sauce,  and  retired  to  obtain  the  sleep 
from  which  she  was  destined  to  awake  in  death. 
At  four  o'clock  the  invasion  took  place,  and  from 
the  progress  of  dissolution,  when  I  saw  her,  she 
must  have  begun  to  die  at  that  hour.    At  half  past 
10  o'clock,  life  was  perfectly  extinct.    Here  is  a 
violent,  and  a  rapid  case,  and  did  the  symptoms 
denote  that  aggravated  inflammation  of  the  bow- 
els, which  should  have  existed,  had  such  been  the 


60 


source  of  the  phenomena  ?  Nothing  can  be  in- 
ferred from  the  pulse,  for  that  was  almost  insensi- 
ble.— The  tongue  was  as  natural  as  in  health. — 
The  more  important  evidence  of  tenderness  of  the 
abdomen  was  totally  wanting, — and  the  profuse 
discharges  of  serum  were  neither  preceded,  nor 
attended  with  pain.  The  patient  protested  against 
a  cataplasm  to  the  abdomen,  as  she  had  been 
much  more  severely  affected  before,  and  had  re- 
covered w^ithout  any  remedy." 

I  am  far  from  believing  that  the  pathologiac  state 
of  the  stomach  and  intestines  has  not  a  very  im- 
portant connexion  with  the  disease,  and  exerts  a 
most  positive  influence  on  the  whole  system  ;  aug- 
menting the  violence  of  the  constitutional  symp- 
toms, and  precipitating  death.  The  common  de- 
velopement  of  the  earliest  symptoms  of  disease 
occurring  in  those  organs, — the  profuse  and  mor- 
bid secretions  which  soon  ensue, — and  the  very 
general  redness  of  the  mucous  or  serous  tissue, — 
render  it  evident,  that  there  is  a  particular  deter- 
mination of  the  morbid  action  to  those  organs  ; — 
and  their  well  known  properties,  and  important 
relations,  can  leave  as  little  doubt,  that  the  whole 
circle  of  sympathies  is  variously  and  extensively 
disturbed.  The  astonishinof  discharore  of  serum 
from  the  mucous  membrane  cannot  be  the  re- 
sult of  a  mechanical  process.  The  vital  proper- 
ties, and  the  modified  functions  of  the  ex- 
treme vessels,  must  be  concerned  in  the  pro- 
duction of  this  fluid  ;  but  the  secretion  is  so 
rapidly  performed,  that  the  component  parts  of 


61 


the  blood  are  separated,  without  supplying  that 
usual  evidence  of  change,  which  marks  the  pro- 
ductions of  analogous  processes.  With  as  much 
propriety  may  it  be  said,  that  the  profuse  dis- 
charge from  the  skin  is  a  simple  exudation  from 
the  blood,  as  the  separation  of  the  serum  by 
the  mucous  membrane  may  be  attributed  to  the 
same  mechanical  principle.  Whether  the  mode 
of  action  be  always  the  same,  or  what  particu- 
lar modifications  may  arise,  it  will  probably  be 
difficult  to  determine.  Dissections  must  be  made 
w'lih  an  especial  reference  to  this  inquiry,  which 
may  yet  reflect  other  light  on  the  pathology  of  in- 
flammation; It  may  yet  appear  that  the  fluidity 
of  the  blood  is  so  affected,  that  its  red  globules 
can  no  longer  enter  the  extreme  vessels  ;  or  per- 
haps, that  the  depletion  of  the  instruments  of  dis- 
ease has  so  modified  their  vital  properties,  that 
irritability  is  rendered  more  obtuse,  and  the  red 
globules  recede  to  the  capillary  system.  Certain 
it  is,  that  the  blanched  appearance  of  the  large 
intestines  is  generally  greatest  as  the  disease  has 
been  protracted,  and  the  discharges  profuse.  I 
know  not  whether  it  be  true,  that  there  exist  more 
of  the  common  evidences  of  inflammation  in  sub- 
jects that  have  not  been  aflfected  with  vomiting 
and  purging,  as  such  instances  are  rare,  and  I 
have  not  witnessed,  nor  can  I  learn  that  dissec- 
tions have  been  made  where  death  has  occurred 
under  these  circumstances.  I  very  recently  at- 
tended the  examination  of  a  robust  subject  at  the 
Grosby-street  Hospital,  who  died  in  a  few  hours 


62 


after  transfusion  with  the  common  saline  solution. 
His  habits  were  intemperate,  and  the  disease  was 
severe  and  rapid.  The  examination  was  made 
about  eight  hours  after  death.  In  this  case,  the 
loss  of  serum  had  been  partially  supplied,  and  of 
course,  the  blood  was  more  than  usually  dilute. 
The  small  intestines  appeared  to  several  ob- 
servers, who  had  witnessed  numerous  dissections 
at  this  and  other  hospitals,  to  exhibit  a  more  vivid 
redness  than  was  recollected  in  any  other  instance. 
The  mucous  tissue  was  very  minutely  injected,  and 
presented,  through  its  whole  tract,  a  uniform 
blush  of  redness.  It  was  studded  with  enlarged 
follicles,  but  its  texture  was  firm  as  in  health. 
There  was  nothing  more  observed  that  can  illus- 
trate my  subject;  but  it  may  be  stated,  that  the 
large  intestines  were  rather  blanched,  and  its  mu- 
cous follicles  were  not  visible  ;  that  the  stomach 
was  large  and  free  from  every  vestige  of  disease  ; 
that  the  liver  and  other  viscera  of  the  abdomen 
were  natural; — the  gall  bladder  full  of  greenish 
yellow  bile,  none  of  which  had  escaped  into  the 
intestines  ; — the  bladder  perfectly  contracted  ; — 
the  lungs  partially  inflated  and  entirely  natural, 
and  the  heart  soft  and  flabby  ; — its  cavities  and  the 
larger  vessels  were  well  filled  with  blood,  nearly 
as  dark,  but  rather  more  fluid,  than  in  those  who 
die  without  the  saline  transfusion. 

It  is  not  improbable,  also,  that  a  contraction 
of  the  extreme  vessels,  may  occur  extensively 
through  the  system,  by  which  the  red  globules 
would  be  further  excluded. 


63 


Although  I  do  not  advance  these  conjectures 
as  probable,  and  believe  that  the  absence  of  the 
usual  phenomena  of  acute  inflammation  is  strong- 
ly indicative  of  some  other  mode  of  action,  I 
could  still  desire,  that  further  investigation  may 
enable  us  to  resolve  this  morbid  state  of  the  in- 
testinal canal  into,  a  modified  form  of  inflamma- 
tion. The  treatment,  not  only  as  respects  these 
organs,  but  also  the  influence  of  their  diseased 
action  on  the  whole  system,  would  then  be  more 
within  the  reach  of  philosophy,  and  those  princi- 
ples which  experience  has  established.  But 
whether  inflammation,  or  some  mode  of  action 
essentially  diflerent,  I  cannot  doubt  that  it  is  only 
a  part  of  an  original  series  of  morbid  actions  as 
extensive  as  the  numerous  functions  of  the 
system. 

There  is  one  analogical  fact,  in  the  view  of  the 
subject  just  taken,  that  may  encourage  the  pre- 
sumption that  the  action  is  allied  to  the  proximate 
cause  of  inflammation.  It  is  now  generally  con- 
ceded that  profuse  haemorrhage  from  the  mucous 
coat,  whether  of  the  stomach  or  intestines,  is  fre- 
quently the  direct  result  of  acute  inflammation,  and 
proceeding  from  the  secretory  organs  of  that  mem- 
brane. It  appears,  therefore,  to  be  a  fair  sugges- 
tion, whether  the  fluid  evacuated,  in  a  great  pro- 
portion of  choleric  subjects,  may  not  be  the  pro- 
duct of  an  action  analogous  to  inflammation.  We 
have  all  the  constituent  parts  of  the  blood  with  the 
exception  of  its  red  globules  ;  and  it  may  be  far- 
ther remarked,  that  as  in  patients  aflfected  with 


64 


Cholera,  the  discharge  is  generally  sudden  and 
profuse, — so  also  in  hsemorrhagic  inflammation  is 
the  evacuation  of  blood  surprisingly  abundant ; — 
and  under  either  circumstance,  the  system  sustains 
the  depletion,  with  less  prostration  of  its  powers, 
than  would  arise  from  any  other  mode  of  abstract- 
ing the  vital  fluid.  Perhaps  not  the  least  remark- 
able incident  attending  this  secretion  of  the  com- 
ponent parts  of  the  blood,  is  the  great  uniformity 
of  its  occurrence  wherever  the  Cholera  has  pre- 
vailed. But  opposed  to  these  conjectures,  which 
may  be  advanced  by  the  advocates  of  inflamma- 
tion, is  nearly  the  whole  symptomatology  of  the 
disease  ;  and  let  it  not  be  imagined,  that  in  having 
thus  given  a  fair  representation  to  the  subject,  I 
am  already  becoming  a  convert  to  the  doctrine 
which  regards  inflammation  of  the  bowels  as  the 
proximate  cause  of  Cholera.  I  am  not  only  willing, 
but  could  even  desire,  for  the  reasons  which  I  have 
assigned,  that  it  may  be  yet  determined  that  this 
mode  of  action  is  analogous  to  something  with 
which  we  are  familiar,  and  the  treatment  of  which 
may  be  embraced  under  the  settled  principles  of 
our  science.  We  shall  have  accomplished  much, 
if  we  can  relieve  the  intestines  of  the  weight  of 
disease  which  they  so  generally  sustain,  and  in 
doing  which  the  constitutional  derangement  will 
be  released  from  an  overwhelming  sympathy, — 
and  the  blood  vessels  will  be  no  longer  exhausted. 

Have  the  Humoral  Pathologists  supplied  us 
with  a  better  solution  of  the  great  problem  of  this 
disease  ?  I  cannot  believe  that  their  philosophy 


65 


will  bear  the  analysis  which  must  ultimately  sus- 
tain the  conclusion  at  which  reason  aspires.  The 
most  critical  examinations  do  not  detect  any 
foreign  substance  in  the  blood,  nor  have  its  ele- 
mentary or  component  principles  formed  any  new 
combinations.  If  the  due  proportion  of  its  con- 
stituent parts  have  been  disturbed,  and  we  find 
a  diminution  of  the  serum  and  the  salts,  by  car- 
rying the  same  investigation  a  little  further,  we 
shall  discover  them  in  the  form  of  secretions,  and 
by  that  very  circumstance,  denoting  the  essential 
agency  of  the  solids  in  their  separation;  But 
before  this  diminution  takes  place,  and  while  yet 
there  are  ample  phenomena  to  evince  the  malig- 
nancy of  morbid  action,  we  find  the  blood  still 
constituted  as  in  health,  and  only  yielding  up  its 
physical  characters  to  the  organized  parts  of  the 
system.  It  is  only  as  disease  advances,  that  this 
vital  fluid  succumbs  to  the  influence  of  the  modi- 
fied powers  and  functions;  and  at  last  when  dis- 
solution begins,  the  changes  have  become  quite 
apparent.  If  diarrhoea  or  vomiting  have  attended 
the  case,  we  discover  an  absence  of  the  serum 
or  the  salts  in  the  ratio  of  those  discharges. 
Hence  we  are  told,  that  the  problem  is  demon- 
strated, and  that  we  have  nothing  to  do  but  to 
replace  the  evacuations.  It  is  then  that  the  lungs 
refuse  to  perform  their  office,  and  respiration  is 
almost  at  a  stand.  What  is  the  unavoidable  re- 
sult of  the  interruption  of  this  function,  no  less 
remarkable  than  the  impaired  action  of  another 
organ,  on  which  so  much  emphasis  is  laid  ?  It 

9 


66 


is  an  imperfect  oxygenation  of  the  blood — and 
therefore  "  oxygen  gas  is  a  specific  for  the  dis- 
ease." This  failure  of  decarbonization  can  never 
be  detected  till  evident  lesions  have  occurred  in 
some  of  the  great  organs  of  life.  Does  the  blood 
sometimes  refuse  to  separate  into  its  component 
parts  ?  This  is  only  so  in  the  advanced  stages 
of  the  disease,  when  other  sensible  changes  have 
been  the  slow^  result  of  the  morbid  process,  and 
may  be  regarded  as  a  rare  phenomenon  if  the 
blood  be  properly  abstracted. 

Perhaps  the  most  remarkable  appearance  at- 
tending this  fluid,  and  which  I  announced  in 
two  cases  lately  reported  to  you,  as  the  dis- 
covery of  Dr.  Gale  of  this  city,  is  the  extrica- 
tion of  the  oil  of  the  blood,  and  its  existence 
in  a  free  state  in  every  part  of  the  vascular  sys- 
tem. If  any  other  accidental  deviations  in  the 
sensible  properties  of  the  blood  have  been  some- 
times observed,  as  its  diminished  fluidity  where 
vomiting  and  purging  had  not  existed,  it  has  only 
been  when  the  organic  powers  have  suflfered  in 
more  than  a  corresponding  ratio;  and  the  com- 
plexity of  that  fluid,  and  its  probable  vitality,  will 
afford  modes  of  accounting  for  such  deviations, 
and  render  the  principle  of  explanation  which  I 
have  adopted  sufficiently  comprehensive.  Do  we 
find  in  the  fluids  secreted  any  evidence  of  a  mor- 
bid condition  of  the  blood?  Let  us  examine  the 
results,  as  the  extinction  of  life  approaches. — 
We  detect  nothing  more  in  the  evacuations  from 
the  alimentary  canal  than  the  component  parts 


67 


of  the  blood  itself.  The  organs  of  secretion 
have  scarcely  produced  any  change  in  their  pro- 
perties,  or  their  relations  to  each  other,  and  it  is 
the  fairest  inference  that  there  is  nothing  here  to 
countenance  the  opinion  of  vitiated  fluids.  If 
Christie,  Annesley  and  others,  discovered  in  the 
intestines  an  opaque,  pultaceous  fluid,  its  exist- 
ence did  not  occur  to  other  observers,  and  I  be- 
lieve has  been  rarely  noticed  in  this  hemisphere. 
The  acid  of  Hermaan  is  now  forgotten,  and  with 
it  his  treatment  is  involved  in  the  same  oblivion. 

The  analyses  of  the  bile,  which  have  been 
made  in  Europe,  have  detected  nothing  unusual 
in  that  fluid,  and  we  discover  no  other  remarkable 
changes  in  the  other  secretions  of  perspiration, 
urine,  and  saliva,  than  their  increase  or  diminu- 
tion, or  some  variations  in  the  proportion  of  their 
constituent  parts. 

However  this  inquiry  may  be  pursued,  we  shall 
find  nothing  to  sustain  the  humoral  pathologist. 
Even  his  very  remedies  discourage  his  philosophy. 
Does  he  endeavour  to  restore  to  the  blood  its  flu- 
idity by  the  transfusion  of  water,  or  recombine  its 
constituent  salts  ?  He  is,  at  most,  elated  only  by 
the  beam  of  hope,  which  for  a  moment  animates 
the  brow  of  his  patient ;  but  who  soon  relapses 
into  the  apathy  of  death,  and  brings  a  chill  over 
the  enthusiast. — That  these  experiments  may 
continue  to  be  repeated  will  be  less  remarkable, 
than  the  blind  zeal  of  Hermaan,  wlio  successfully 
promulgated  an  hypothesis  in  Russia,  which  Ains- 
lie  had  imagined  and  Annesley  refuted  in  India. 


68 


The  acid  was  fully  demonstrated  not  to  exist  in 
the  secretions,  and  it  was  no  less  shown  that  it 
could  be  only  detected  in  its  natural  combinations 
in  the  blood.  Has  the  saline  treatment  of  Wil- 
liam Stevens  been  attended  with  better  success  ? 
There  is  good  reason  to  believe,  that  even  in  tropi- 
cal fever,  which  he  esteems  a  kindred  of  Cholera, 
the  principal  agents  were  blood-letting  to  an  ex- 
tent of  30  or  60  ounces,  calomel,  emetics,  sul- 
phate of  quinine  and  Croton  oil.*  It  is  useless 
to  multiply  objections.  I  know  of  no  remedy, 
suggested  by  this  hypothesis,  that  experience  has 
sanctioned,  or  that  has  not  left  the  projector  its 
Bolitary  advocate. 

In  conclusion  of  this  subject,  it  is  difficult  to 
understand  how  the  morbific  poison  can  produce 
a  direct  influence  on  the  blood,  even  if  the 
vitality  of  that  fluid  be  fully  conceded.  It  is  suf- 
ficiently difficult  of  apprehension,  that  the  agency 
of  the  virus  is  originally  through  some  part  of  the 
system,  more  material  and  more  eminently  en- 
dowed with  the  properties  of  life.  That  its  pri- 
mary action  is  exerted  on  the  great  source  of 
sympathy  and  sensibility  is  even  hypothetical, 
and  although  from  the  susceptibility  of  this  sys- 
tem of  organs  to  external  impressions  this  is  the 
most  intelligible  solution,  it  is  still  so  impossible 


*  Vide  Medico-Chirurgical  Review,  vol.  xx.  280. — My  friend 
Dr.  Holmes,  of  Montreal,  informs  me  that  he  has  tried  Dr.  Stevens' 
method  in  a  few  instances  unsuccessful]}'.  I  have  not  known  any 
useful  results  from  it  in  New  York. 


69 


to  comprehend  the  mode  of  action,  that  the  mind 
involuntarily  glances  to  other  organs,  or  even  to 
the  unorganized  blood,  and  seems  to  find  repose 
in  the  greater  darkness  by  which  the  subject  be- 
comes enveloped.  If  the  poison  be  introduced 
and  combined  with  the  blood,  as  maintained  by 
Searle,  Stevens,  Desruelle  and  others,  the  fact  must 
be  shown,  before  the  doctrine  can  be  tenable.  Is 
the  supposition  that  the  poison  produces  its  first 
impression  on  the  solids  more  encumbered  with 
difficulty,  than  that  which  introduces  it  into  the 
blood  through  the  medium  of  an  organized  part, 
and  then  supposes  that  in  the  course  of  its  dis- 
tribution, and  thus  diluted,  it  produces  the  physi- 
cal changes  through  the  system  ;  or,  than  that 
which  maintains  that  a  direct  and  primary  im- 
pression is  made  on  the  blood  itself,  by  which 
the  subject  is  not  only  embarrassed  with  the  in- 
explicable mode  in  which  that  change  is  produced, 
but  there  is  superadded  an  equal  difficulty  in  ex- 
plaining the  possible  manner  in  which  the  blood, 
thus  diseased,  so  suddenly  and  so  fatally  deranges 
every  function  of  life  ?  The  existence  of  the 
poison  is  absolutely  hypothetical,  and  is  only  in- 
ferred from  the  necessity  of  supposing  some  uni- 
versal cause,  and  from  a  long  series  of  analogies; 
not  from  our  ability  to  detect  its  presence  in  any 
mode  of  its  existence.  I  need  not  therefore  say, 
that  the  difficulty  increases  as  we  attempt  to  in- 
troduce an  imaginary  substance  into  the  circula- 
tion, and  that  the  design  becomes  utterly  vision- 
ary, when  we  afterwards  direct  its  influence  to 


70 


the  organized  system.  Even  the  oxygen  gas  of 
the  air,  as  stated  by  Stevens,  is  not  attracted 
into  the  circulation," — nor  even  its  azotic  prin- 
ciple,— an  assumption  which  was  important  to 
illustrate  his  doctrine.*  If  this  negative  fact  prove 
any  thing,  it  is  opposed  to  the  opinion  of  that 
gentleman. 

It  will  be  an  interesting  inquiry  to  ascertain 
whether  the  polypyform  lymph  observed  by  M. 
Marcus  and  his  associates,  and  which  is  frequent- 
ly noticed  in  this  city,  be  sometimes  produced 
before  death,  and  how  far  it  becomes  a  mechani- 
cal cause.  I  have  witnessed  it  in  subjects  as  ear- 
ly as  five  or  six  hours  after  dissolution,  when  the 
lymph  was  abundant  and  had  acquired  almost  an 
organized  appearance ;  and  others  assert  that 
they  have  found  it  within  the  short  space  of  half 
an  hour. 

Many  enlightened  pathologists  ascribe  the  seat 
of  Cholera  to  the  nervous  system,  either  without 
limitation,  or  restricting  it  to  the  nerves  of  the 
bas-ventre.  Hence  we  have  the  doctrine  of  di- 
minished nervous  energy,  and  of  central  ganglion- 
ite,  and  ganglionite  neurilematic  peripherique. 
But  are  there  any  uniform  indications  that  ei- 


will  afterwards,"  says  Dr.  Stevens,  "bring  forward  some 
very  strong  facts  to  prove,  that  the  aerial  poisons  which  act  as  the 
remote  cause  of  the  essential  fevers,  do  not  produce  their  effect  by 
any  direct  impression  on  the  nervous  system;  on  the  contrary,  they 
appear,  like  the  oxygen  of  the  air,  to  be  attracted  into  the  circula- 
tion, and  produce  their  effects  on  the  solids  of  the  system,  entirely 
through  the  medium  of  the  blood." 


71 


ther  system  of  nerves  has  sustained  that  impres- 
sion, which  is  subsequently  developed  in  the  other 
great  organs  of  life  ;  or  any  lesions  of  that  system, 
through  the  whole  progress  of  the  disease,  that 
bear  any  correspondence  with  the  morbid  pheno- 
mena of  other  organs ;  or  are  there  any  symptoms 
which  denote  even  a  primary  invasion  of  the 
nerves  ?    We  have  so  little  to  direct  us  in  this  in- 
vestigation, that  the  question  will  probably  always 
remain  undetermined,  whether  it  be  through  the 
medium  of  this  or  some  other  tissue,  that  the 
poison  deranges  the  general  functions.    But  that 
the  brain  and  nerves  are  not  the  primary  seat  of 
Cholera, — that  they  subsequently  participate  lees 
than  some  other  organs  in  the  morbid  action,  and 
at  most,  do  but  serve  to  transmit  the  impression 
they  may  receive  from  the  morbific  agent  to  other 
parts  of  the  system,  I  think  may  be  nearly  demon- 
strated.   If  we  look  at  the  mind,  we  shall  find  it 
'^sitting  unimpaired  and  serene  amidst  the  ruins 
of  organic  life."    Respiration  is  only  performed 
by  the  voluntary  muscles, — pulsation  has  long 
ceased  in  the  extremities, — the  heart  has  become 
inaudible  to  the  stethoscope, — yet  the  integrity  of 
the  mind  remains  undisturbed ;  and  the  indiffer- 
ence with  which  it  contemplates  the  wreck  over 
which  it  presides,  proves  that  at  least  its  peculiar 
and  last  abode  in  the  body  is  still  its  own  uninva- 
ded  possession. 

The  powers  of  the  mind  are  fully  exercised  in 
respect  to  the  voluntary  muscles ;  and  it  is  not 
unusual  to  witness  successful  attempts  at  walk- 


72 


ing  when  the  pulsations  of  the  heart  are  only 
sensible  to  the  ear.  These  phenomena  are  cer- 
tainly not  coincident  with  the  attendant  symp- 
toms of  other  organs.  The  functions  of  the 
brain  are  wholly  undisturbed,  while  the  heart 
and  the  lungs,  and  all  the  viscera  of  organic  life, 
are  involved  in  a  chaos  of  disordered  action. 

Animal  sensibility  is  not  known  to  be  particu- 
larly affected,  till  near  the  termination  of  life. 
It  is  scarcely  augmented  or  diminished,  or  in 
any  way  modified, — a  remarkable  circumstance, 
if  we  regard  the  common  influence  of  disease  on 
that  property,  and  which  serves  to  demonstrate 
the  little  participation  of  the  nervous  system  in 
the  great  conflict  of  nature.  The  sufferer  is 
even  conscious  of  the  unequal  distribution  of 
heat,  and  feels  as  intensely  as  in  health,  the  ac- 
tion of  stimulants  upon  the  cold,  and  shrivelled 
and  livid  surface  of  his  body.  He  hears  and  sees 
with  a  natural  acuteness.  The  functions  of  sen- 
sation, therefore,  remain  unimpaired,  and  the 
great  office  of  the  cerebral  system  goes  on  to  the 
last  moment. 

But  these  are  facts  with  which  all  observers 
are  familiar,  and  render  the  hypothesis  of  di- 
minished nervous  energy  entirely  paradoxical. 
The  vital  properties,  with  which  the  different 
parts  of  the  system  are  endowed,  are  certainly 
not  derived  from  the  cerebral  nerves ;  and  the 
sympathetic  system,  as  is  imported  by  its  very 
name,  is  chiefly  destined  to  maintain  a  connexion 
between  the  complex  parts  of  the  most  organized 


7<^ 
o 

bodies.  The  various  properties,  by  which  the 
functions  of  organs  are  performed,  exist  in  them 
independently.  The  analogies  derived  from  vege- 
tables, and  the  inferior  animals,  in  proof  of  this 
fact,  are  too  familiar  to  be  repeated,  and  illustrate 
the  peculiar  office  of  the  sympathetic  system.  Irri- 
tability, mobility,  &c.  are  implanted  in  the  organs 
which  they  are  designed  to  govern,  and  where  we 
find  them  peculiarly  modified  and  adapted  to  the 
purposes  of  each  individual  part ;  and  perhaps  it  is 
not  improbable  that  the  brain  itself,  in  respect  to 
its  organic  life,  is  sustained  by  properties  quite 
independent  of  the  nervous  power.  If  the  prin- 
ciples of  life  were  imparted  by  the  nerves,  and 
there  were  really  a  diminution  of  nervous  power, 
how  does  it  happen  that  irritability,  contractility, 
<fec.  are  so  exalted  in  some  organs,  that  there 
are  frequently  mnifested  evidences  of  conges- 
tion or  inflammation,  which  have  been  assumed 
as  the  ground  of  a  doctrine  I  I  cannot  but  regard 
it,  therefore,  as  an  axiom  in  physiology,  that  vi- 
tality, which  is  made  up  of  the  several  proper- 
ties of  life,  is  the  specific  endowment  of  every 
organ.  The  vague  designation  of  nervous  ener- 
gy is  wholly  another  subject,  and  has  no  neces- 
sary connexion  with  those  powers  which  are  so 
overwhelmed  in  Asphyxiated  Cholera.  That 
the  nerves,  in  their  office  of  maintaining  inter- 
nal, and  perhaps  also  their  external,  relations, 
and  transmitting  sympathies,  may  convey  in 
some  mysterious  manner  morbific  impressions  to 
the  propertio^;  of  other  organs,  is  more  than  pro- 

10 


74 


bable ;  but  it  cannot  be  said,  that  vitality  is  af- 
fected till  the  poison  has  reached  the  seat  of  that 
principle.  In  what  manner,  then,  does  the  mor- 
bific agent  make  its  impression  on  the  nerves, 
and  is  it  through  the  specific  irritability  of  that 
system,  that  that  impression  is  transmitted  to 
the  powders  or  properties  of  other  organs  ? 

In  respect  to  the  ganglionic  system,  if  we  could 
attribute  to  it  any  other  function,  than  that  of 
establishing  a  circle  of  sympathies  between  the  or- 
gans which  it  supplies,  the  hypothesis  which  as- 
signs to  it  the  proximate  cause  of  Cholera  must 
utterly  fail  from  the  want  of  pathological  evi- 
dence. But  from  the  fact  that  this  intercommu- 
nication is  maintained  by  the  systems  of  nerves, 
and  the  simultaneousness  with  which  the  Cho- 
lera is  often  developed  in  the  several  viscera  of 
organic  life,  I  cannot  doubt,  that  they  are  not 
only  interested  in  the  process  as  organs  of  sym- 
pathy, but  have  sustained  an  original  part  in  the 
incubation  of  the  disease. 

All  the  doctrines,  subordinate  to  this  general 
principle  of  the  failure  of  nervous  power,  must 
necessarily  fall,  if  the  original  hypothesis  cannot 
be  maintained.  We  shall  no  longer  understand 
how  the  "  heart  is  paralyzed"  if  we  look  not  be- 
yond the  nerves  with  which  it  is  so  slightly  sup- 
plied. Irritability  and  muscular  power  are  pre- 
dominant properties  of  the  organ,  and  its  sensi- 
bility is  almost  latent.  We  do  not  find  that  the 
latter  is  in  any  way  modified  ;  but  the  former 
powers  which  belong  to  the  constitution  of  the 
heart  are  most  surprisingly  disturbed.    It  is  with 


75 

this  organ,  as  with  the  rest  of  the  system  ;  its 
properties  and  functions  liave  become  involved 
in  the  operation  of  the  common  predisposing 
cause  ;  and  perhaps  it  is  less  remarkable,  that  it 
should  evince  more  of  the  morbid  impression, 
from  the  eminent  manner  with  which  it  is  en- 
dowed with  irritability,  and  from  the  general  ma- 
lignancy of  the  disease. 

But  my  letter  is  running  to  an  extraordinary 
length,  and  I  have  already  presumed  too  much 
on  your  time, — and  I  fear,  too,  on  the  interest  of 
my  own  speculations.  I  shall  therefore  proceed, 
in  a  few  words,  to  express  the  opinion  which  I 
have  been  led  to  form  of  the  nature  and  philoso- 
phy of  this  disease. 

I  believe  that  the  proximate  cause  of  Cholera 
Asphyxia  consists  in  a  simultaneous  modification 
of  all  the  organic  powers  and  functions^  produ- 
ced by  some  unknown  morbific  poison,  acting 
either  directly  on  the  properties,  or  transmitted 
indirectly  through  the  nervous  system.  I  am  dis- 
posed to  think,  that  the  primary  impression  is  on 
the  organs  of  sensation  and  sympathy,  and  per- 
haps through  the  organic  properties  of  that  sys- 
tem. This  change  so  produced  is  not  merely  a 
depression  of  the  vital  powers,  but  there  is  proba- 
bly an  alteration  of  their  specific  character,  as 
seems  to  be  denoted  by  the  remarkable  derange- 
ment of  some  of  the  functions.  The  constitu- 
tional disease  has  been  sometimes  so  suddenly 
developed  and  so  rapid  in  progress,  that  the 
powers  of  life  have  appeared  to  be  at  once  ex- 
tinguished. 


76 


That  this  modification  is  general  and  simulta- 
neous will  appear  from  the  phenomena  which  dis- 
tinguish the  invasion.  We  must  look  at  them, 
however,  in  the  most  simple  and  uncombined 
form  of  the  disease  ;  not  as  they  occur  in  those 
complex  cases  that  may  be  variously  introduced 
by  premonitory  symptoms."  Those  are  in- 
stances in  which  cither  the  epidemic  poison,  or 
accidental  causes  more  or  less  frequently  applied, 
produce  some  local  derangement,  generally  of 
the  organs  of  digestion,  which  subsequently  be- 
comes an  exciting  cause  of  the  constitutional 
disease.  Those  are  instances  in  which  I  hold, 
that  there  exists  only  local  disease,  which  ulti- 
mately developes  the  specific  action  of  Cho- 
lera. The  exciting  causes  of  those  premonitory 
symptoms  may  also  co-operate  with  the  local  dis- 
turbance, in  producing  the  general  affection  ;  and 
indeed  it  frequently  happens,  that  the  predisposi- 
tion to  Cholera  is  so  slightly  formed,  that  the  local 
disease  subsides  spontaneously,  if  its  exciting 
causes  be  withheld,  and  that  the  general  develope- 
ment  is  only  produced  by  an  aggravated  state  of 
an  almost  artificial  disease.  That  the  miasm  itself 
may  produce  derangement  of  particular  organs 
is  not  opposed  to  the  doctrine  I  advocate,  as  we 
have  parallel  instances  in  other  epidemics. 

These  complicated  cases  of  Cholera  do  not  offer 
to  the  pathologist  the  unembarrassed  data,  which 
may  be  found  in  the  less  complex  forms  of  the 
disease.  If  we  assume  a  local  proximate  cause  of 
the  disease,  we  sliould  always  be  able  to  detect  its 


77 


existence  ;  but  we  have  now  been  presented  in  • 
New- York  with  many  cases  in  which  the  invasion 
of  the  most  malignant  constitutional  symptoms 
was  abrupt,  and  in  which  there  could  not  be  de- 
tected a  solitary  evidence  of  antecedent  local 
disease.  I  have  known  the  attack  to  have  taken 
place  in  the  most  robust  subjects  while  sitting  at 
their  breakfast,  in  the  apparent  enjoyment  of  entire 
health  ;  and  I  have  seen  them  die  within  five  or  six 
hours  after.  The  invasion  has  arisen  from  the 
strength  of  the  predisposition,  and  these  cases  I 
believe  to  be  always  fatal. 

Spasms  are  well  known  to  occur  extensively  in 
some  places  during  the  prevalence  of  Cholera, 
without  any  other  symptom  denoting  the  epidemic 
influence  ;  and  at  other  times  a  suppression  of 
urine  has  happened  to  many  in  certain  endemics 
of  this  disease,  without  any  other  derangement  of 
the  health.  As  well  might  such  a  subject  be  con- 
sidered a  choleric,  as  he  who  suffers  the  pre- 
monitory diarrhoea,"  and  those  local  derangements 
might  as  well  constitute  the  "first  stage"  of  Asphyx- 
iated Cholera.  The  transition  from  premonitory 
diarrhoea  to  the  constitutional  symptoms  is  cer- 
tainly sudden  in  tliis  city,  however  it  may  have 
been  by  slow  degrees  in  other  countries.  The 
patient  can  often  define  the  very  moment  of  the 
constitutional  invasion,  and  the  precision  with 
which  it  is  done  seems  alone  to  distinguish  the 
diseases. 

There  is  nothing  in  this  simple  form  of  the  dis- 
ease that  denotes  an  original  locality  ;  and  if  in  its 


78 


•  progress,  or  even  at  its  invasion,  we  find  one  organ 
sustaining  more  of  the  burthen  than  another,  and 
vice  versa,  it  is  only  what  is  constantly  witnessed 
in  other  constitutional  affections,  and  does  but 
arise  from  their  varying  susceptibilities,  or  the 
idiosyncrasies  or  other  accidents  appertaining  to 
the  subject. 

It  follows  from  the  principles  which  I  have  en- 
deavoured to  advocate,  that  the  extreme  vessels 
must  be  the  instruments  of  this  disease,  and  it  is 
upon  those  organs  that  we  must  make  an  impres- 
sion in  the  treatment.  One  of  the  morbid  condi- 
tions is  a  general  contraction  over  the  whole  body. 
This  will  explain  some  of  the  vital,  and  some  of 
the  more  mechanical  phenomena.  It  will  account 
in  part  at  least  for  the  carbonization  of  the  blood, 
which  can  no  longer  pursue  its  unembarrassed 
course  through  the  lungs  ;  it  will  account  in  part 
also,  for  the  shrinking  of  the  skin,  and  the  col- 
lapse of  the  features.  Such  a  universal  contrac- 
tion must  affect  the  general  circulation  and  contri- 
bute to  the  venous  congestion,  and  probably  pro- 
duces a  strong  impression  on  the  heart  through  the 
medium  of  sympathy.  But  doubtless  more  is  ow- 
ing to  the  nature  of  the  morbid  action  itself.  It 
is  established  in  every  organ  ;  in  the  liver  and 
kidneys  it  is  especially  denoted  by  the  failure  of 
their  secretions.  It  is  a  useless  multiplication  of 
causes  to  ascribe  the  deficiency  of  bile  to  the 
failure  of  digestive  excitement ; — and  its  disap- 
pearance from  the  evacuations  has  been  unneces- 
sarily assigned  to  a  contraction  of  the  ducts  from 


79 


irritation  of  the  intestinal  mucous  membrane.  We 
constantly  find  nearly  the  same  quantities  of  bile 
in  the  vesicle  after  death  from  other  diseases,  and 
it  is  not  usual  in  Cholera  for  that  organ  to  be 
distended  ; — nor  have  I  ever  been  able  to  detect 
more  than  a  trace  of  bile  in  the  liver,  and  often 
none.  If  we  generally  find  no  urine  remaining, 
it  is  because  the  bladder  is  a  voluntary  organ,  and 
participates  also  in  the  muscular  spasm.  Thekid- 
neys  being  more  isolated,  have  been  permitted  to 
take  their  full  share  in  the  constitutional  affection. 
So  also  has  the  heart,  and  the  remarkable  flabbi- 
ness  of  this  organ,  which  I  have  frequently  wit- 
nessed, denotes  something  more  than  sympathetic 
derano^ement ;  thouojh  I  cannot  doubt  that  its  em- 
barrassed  action  is  owing  also  to  the  influence  of 
sympathy  from  different  sources. 

Perhaps  there  is  no  symptom  that  more  strong- 
ly evinces  the  constitutional  derangement  than  the 
failure  in  the  production  of  heat.  This  is  one 
of  the  earliest,  and  most  general  phenome- 
na, and  exists  in  every  part,  excepting  the  epi- 
gastric region,  where  it  sometimes  accumu- 
lates in  a  morbid  and  remarkable  degree. 
The  coldness  of  the  breath  and  extremities, 
the  generation  of  heat  in  the  vicinity  of  the  liver 
and  stomach,  and  its  distribution  from  this 
part  over  the  system,  after  the  laws  of  vitality 
cease  to  operate,  are  proofs  of  its  production,  by 
a  vital  process,  and  that  its  organs  of  secretion 
are  universally  involved  in  disease. 

In  reverting  once  more  to  that  })lausible  theory 


80 


which  refers  the  proximate  cause  of  Cholera  As- 
phyxia to  the  intestinal  canal,  and  which  is  neces- 
sary to  its  identity  with  cholera  morbus,  I  cannot 
but  conclude,  for  the  reasons  I  have  stated,  that 
there  is  little  evidence  that  the  local  derangement 
is  the  primary  result  of  the  action  of  the  morbific 
poison  as  constituting  the  general  disease,  whether 
we  advert  to  the  symptoms,  or  repose  the  decision 
on  morbid  appearances.  In  the  succession  of 
phenomena  which  mark  the  invasion  or  the  pro- 
gress of  Cholera,  we  sometimes  notice  other  symp- 
toms long  anterior  to  any  evidence  of  the  exten- 
sion of  the  disease  to  the  bowels,  or  we  find 
simultaneous  disturbances  in  other  organs  not  less 
remarkable.  Dissections  are  no  more  conclusive 
as  to  the  proximate  cause,  and  it  would  be  idle  to 
repeat  the  results  which  establish  the  want  of  that 
uniformity  which  can  only  sustain  an  important 
principle  ;  results,  which  might  with  nearly  equal 
propriety,  refer,  indiscriminately  to  any  of  the  great 
organs  of  life,  the  seat  of  the  disease.  This  va- 
riety of  local  developements  alone  carries  us  to  the 
true  philosophy  of  the  disease  ;  and  when  it  shall 
be  established  that  the  whole  system  is  simulta- 
neously impressed  by  the  morbific  poison,  then 
shall  we  understand  why  one  organ,  more  suscep- 
tible in  one  individual  than  in  another,  or  more 
subject  to  the  influence  of  those  sympathies  by 
which  it  is  connected  with  the  whole  system,  and 
vice  versa,  is  found  sustaining  more  or  less  than  a 
proportion  of  the  morbid  action,  and  in  its  necro- 
scopic  character  supplying   corresponding  evi- 


81 


dence  of  disease.  Then  may  we  comprehend 
the  greater  coincidence  in  the  vital  phenome- 
na, than  in  the  morbid  appearances  ;  and  can 
better  understand  the  rapid  destruction  of  the 
powers  of  life  where  the  whole  system  participates 
in  the  invasion,  than  by  referring  these  astonish- 
ing events  to  the  influence  of  disease  as  establish- 
ed in  a  single  organ. 

If  what  has  been  denominated  "  premonitory 
diarrhoea"  be  regarded  only  as  the  result  of  some 
local  affection,  and  ultimately  becoming  an  exci- 
ting cause  of  the  constitutional  derangement, — 
then  will  be  explained  the  mystery  which  has  en- 
veloped the  issue  of  the  treatment,  when  applied 
under  circumstances  of  local  or  general  disease  ; — 
then  may  we  comprehend  how  abstinence  alone, 
when  diarrhoea  portends  the  danger,  will  enable 
nature  to  effect  her  escape, — or  how  it  happens 
when  neglected  for  a  day  or  an  hour,  it  becomes 
the  exciting  cause  of  a  perilous  disease,  which  had 
been  but  the  preceding  moment  in  a  state  of  incu- 
bation, and  which  now  baffles  the  efforts  both  of 
nature,  and  of  art ; — or  if  submissive  in  cases  of 
rare  felicity,  its  successive  and  capricious  deve- 
lopements  still  require  the  vigilance  of  zeal,  and 
the  decision  of  a  firm  observer,  to  conduct  it  to  a 
slow  and  successful  issue. 

My  construction  of  the  antecedent  diarrhoea  is 
rendered  still  more  probable  from  its  general  ab- 
sence in  Asia,  a  circumstance  particularly  noticed 
by  some  of  the  oriental  writers.    If  it  be  true  that 

11 


82 


it  has  occurred  more  remarkably  in  Europe  and 
America,  as  a  premonitory  symptom,  it  only  fur- 
nishes an  evidence  that  there  exists  some  modifica- 
tion of  the  predisposing  cause,  by  which  a  local 
disease  is  produced  before  the  system  becomes 
sufficiently  imbued  with  the  poison  for  a  sponta- 
neous developement  of  Cholera.  The  disturb- 
ances which  arise  in  the  alimentary  canal,  as 
attendant  on  the  constitutional  disease,  have  been 
every  where  observed,  with  isolated  exceptions, 
and  they  have  been  among  the  primary  symp- 
toms of  Asphyxia.  We  hence  infer  that  the 
choleric  atmosphere  produces  a  particular  de- 
termination of  disease  to  those  organs  ;  and 
from  the  impaired  digestion  which  is  sustained  by 
most,  during  the  prevalence  of  the  epidemic,  it  is 
not  difficult  to  comprehend  a  circumstance  which 
is  strictly  analogous  to  the  phenomena  of  other 
epidemics, — that  the  malaria  may  produce  in  one 
a  depression  or  change  in  the  gastric  powers, — 
and  in  another  some  functional  derangement  of 
the  bowels,  without  exerting  its  malign  impres- 
sion on  the  whole  system  ;  or,  if  its  influence  be 
so  extensive,  the  local  affection  becomes  rather 
an  exciting  cause  of  the  more  general  and  inde- 
pendent disease,  than  existing  as  an  integral  part, 
until  the  general  developement. 

I  regard  the  Cholera  Asphyxia  as  a  yiova  pestis 
in  Europe  and  America,  and  only  known  in  Asia 
within  the  last  half  century.  I  cannot  recognise 
its  parallel  in  ancient  or  modern  authors.  I  consi- 


83 


der  it  a  fever,  of  which  the  collapse  is  the  first 
stage,  and  reaction  the  second.  The  local  de- 
terjninations  which  arise  in  the  second  stage 
are  not  necessary  to  the  disease,  but  are  acci- 
dental. 


Very  respectfully,  &c. 


84 


LETTER  VL 


New-York,  September  lOth,  1832. 

Dear  Sir, 

Having  submitted  to  your  consideration  my 
reasons  for  believing  the  Cholera  Asphyxia  to  be 
a  constitutional  disease,  I  would  present  you  in 
this  letter  with  a  brief  analysis  of  the  Epidemic 
as  it  has  occurred  in  this  city.  I  have  already 
stated  the  circumstances  under  which  the  irrup- 
tion took  place,  and  without  adverting  to  what 
may  be  regarded  as  its  statistics,  I  shall  proceed 
at  once  to  detail  its  phenomena,  and  shall  be- 
gin with 

A  general  description  of  the  disease.  The  dis- 
ease first  presented  itself  on  the  27th  of  June,  and 
attained  its  height  about  the  20th  of  July ;  after 
which  it  declined  till  the  first  of  September,  when 
it  again  increased,  though  not  extensively.  It  has 
long  been  remarked  in  other  countries,  that  the 
Cholera  makes  its  attack  in  the  night,  and  part  i- 
cularly  towards  the  approach  of  day.  Ithinkithas 
so  happened  in  New- York  in  a  majority  of  cases  ; 
and  the  next  period  most  common  is  in  the  morn- 
ing soon  after  breakfast,  and  the  next  in  the  af- 
ternoon. I  allude,  of  course,  to  the  accession  of 
the  malignant  symptoms,  which  is  generally  al- 


85 


most  instantaneous.  The  patient  is  suddenly 
disturbed  with  a  sense  of  nausea,  and  oppression 
near  the  region  of  the  stomach,  or  of  exhaustion 
or  vacuity  at  that  organ,  and  there  immediately 
follows  a  movement  or  a  commotion  of  the  bowels. 
A  feeling  of  coldness  invades  the  whole  body, 
though  rarely  exceeding  chilliness.  Vomiting 
and  purging  now  occur  simultaneously,  and  if 
diarrhoea  had  previously  existed,  the  evacuations 
from  the  bowels  exhibit  the  appearance  of  rice 
water,  in  which  is  diffused  a  moderate  portion  of 
flocculent  matter,  that  soon  subsides  to  the  bot- 
tom of  the  vessel,  leaving  the  fluid  more  like  the 
appearance  of  common  water.  The  nature  of 
the  first  ejections  from  the  stomach  will  depend 
on  the  ingesta  that  may  remain  in  that  organ, 
and  subsequently  they  assume  the  appearance  of 
the  dejections.  This  intestinal  commotion  is 
attended  with  various  degrees  of  pain  or  distress, 
or  sometimes  there  only  arises  a  feeling  of  ex- 
haustion, and  the  prostrating  effect  from  vomit- 
ing. An  insatiate  thirst  ensues,  which  becomes 
more  intense  and  annoying  as  the  disease  ad- 
vances. The  next  symptoms  in  the  order  of  suc- 
cession, are  a  general  languor,  and  incipient 
listlessness.  The  pulse  begins  to  contract, 
and  increase  in  frequency.  The  skin  is  losing 
its  natural  warmth,  the  nose  becomes  cold,  and 
the  patient  either  complains  of  increasing  rigor, 
or  admits  its  existence.  He  now  seeks  repose, 
often  feeling  some  vertigo,  or  replying  that  he 
hears  a  buzzing,  or  noise.  The  abdominal 
muscles  are  found  contracted,  and  sometimes 


80 


feel  like  a  board,  though  no  spasm  exist.  At 
other  times  they  are  doughy  or  are  natural.  A 
sense  of  tenderness  is  sometimes,  but  not  severe- 
ly felt,  and  the  abdomen  may  generally  be  press- 
ed without  producing  uneasiness.  Locomotion 
is  impaired,  but  the  patient  is  often  able  to  walk 
till  near  the  extinction  of  life.  Spasms  soon  be- 
gin to  ensue,  affecting  particularly  the  muscles 
of  the  feet  and  toes,  but  often  the  corresponding 
muscles  of  the  upper  extremities,  and  sometimes 
those  of  the  body,  though  more  rarely  the  mus- 
cles of  respiration.  The  pulse  now  becomes 
smaller  and  more  accelerated.  Perspiration 
breaks  out  on  the  skin,  and  every  effort  at  vo- 
miting increases  its  profusion.  The  tempera- 
ture continues  to  sink,  and  the  thermometer  now 
evinces  a  general  interruption  of  the  calorific 
function.  Restlessness  increases,  and  jactation 
begins.  The  skin  is  becoming  corrugated  around 
the  fingers  and  hands,  and  the  same  appearance 
is  often  remarked  on  the  feet  and  toes.  This 
symptom  frequently  increases  till  it  exhibits  the 
appearance  of  great  emaciation,  the  skin  lapping 
in  folds.  The  countenance,  which  had  become 
anxious,  now  assumes  a  pathognomonic  expres- 
sion. The  features  contract,  but  are  less  hippo- 
cratic  than  observed  in  the  East.  The  eye 
partially  retreats,  and  the  nose  is  pinched.  List- 
lessness  has  now  grown  into  indifference,  and  the 
attention  of  the  patient  is  only  arrested  by  suf- 
fering or  by  an  inquiry.  Abdominal  distress  in- 
creases or  supervenes.  Respiration  becomes 
more  and  more  embarrassed,  and  sighing  comes 


87 


in  to  its  relief.  The  countenance  assumes  a 
uniform  leaden  hue,  or  extravasation  of  blood 
converts  it  to  an  African  complexion.  The  skin 
preserves  its  sensibility,  but  its  irritability  is  al- 
most extinguished.  The  patient  is  often  aware 
of  its  coldness,  though  he  frequently  complains 
of  heat,  arid  stimulants  applied  externally  will 
often  act  as  soon  on  his  sensibility  as  in  health. 
But  not  so  the  irritability ;  there  is  no  inflamma- 
tion from  the  most  potent  of  the  ordinary  appli- 
cations, and  it  is  even  with  difficulty  that  any 
vascular  excitement  can  be  produced.  The  thirst 
which  existed  from  an  early  period,  is  now  im- 
portunate, and  induces  more  complaint  than  any 
other  species  of  suffering.  The  tongue  is  gene- 
rally coated  in  the  centre,  and  clean  at  the  tip 
and  edges,  and  almost  constantly  moist,  and  be- 
comes colder  and  colder  as  death  approaches. 
The  breath  announces  the  same  subsidence  of 
internal  heat,  and  the  hand  is  chilled  on  the  ex- 
tremities, while  it  sometimes  burns  when  applied 
to  the  region  of  the  epigastrium.  If  this  lan- 
guage be  strong,  it  is  intended  to  convey  a  sense 
of  the  contrast  which  can  be  in  no  other  way  im- 
parted. The  voice  becomes  guttural  and  feeble, 
or  is  depressed  to  a  whisper.  The  secretion  of 
urine  has  been  suspended  from  the  invasion,  and 
the  patient  will  sometimes  advert  to  the  circum- 
stance when  far  advanced  in  the  stage  of  collapse. 
If  the  spasms  continue,  he  will  sometimes  insist  on 
walking  for  his  relief,  when  every  other  symptom 
announces  the  near  extinction  of  organic  life.  If 


88 


blood  have  been  taken  after  a  full  developement 
of  the  disease,  it  is  unusually  dark  and  is  obtained 
with  difficulty.  The  pulse  becomes  tremulous, — 
it  is  no  longer  felt, — the  action  of  the  heart  is  only 
known  by  the  stethescope, — respiration  is  per- 
formed by  the  voluntary  muscles,  and  yet  the  mind 
tranquil  and  almost  undisturbed  in  its  functions, 
till  absolute  death  severs  the  connexion. 

These  phenomena  represent  the  common  pro- 
gress of  Cholera  Asphyxia  when  it  advances  with- 
out interruption  to  a  fatal  termination.  It  will  be 
seen  that  they  are  nearly  parallel  with  those  which 
have  characterized  the  disease  in  Europe  and 
Asia.  Some  of  the  symptoms  have  been,  doubt- 
less, modified  by  climate  and  other  accidents, 
which  it  will  be  the  remaining  object  of  this  letter 
to  illustrate  ;  but  their  coincidence  is  so  remarkably 
striking,  that  we  contemplate  the  disease  with  the 
greater  astonishment.  In  the  early  part  of  Sep- 
tember, the  Cholera,  after  having  subsided  for 
several  days  to  some  20  or  30  cases,  again  increas- 
ed, and  became  more  sudden  in  its  invasion.  It 
was  often  unaccompanied  by  any  of  the  former 
"  premonitory  symptoms,"  but  its  victims  were  fre- 
quently struck  down  at  a  blow,  and  became  im- 
mediately pulseless.  Such  patients  were  unsus- 
ceptible of  any  action  from  remedies,  and  generally 
perished  in  a  few  hours.  They  afforded  examples 
of  the  true  and  unmixed  character  of  the  disease, 
and  very  distinctly  illustrated  its  identity  with  the 
Asiatic  epidemic.  Jactation,  and  oppression  at  the 
preecordia,  were  also  remarkable  symptoms  in  such 


89 


cases.  There  was  no  tenderness  of  the  abdomen, 
and  but  little  or  no  pain  accompanied  the  purging. 

When  the  second  stage,  or  that  of  reaction  took 
place,  there  was  a  simultaneous  abatement  of  the 
most  appalling  symptoms.  The  pulse  began  to 
rise  and  the  features  to  expand.  Purging  and 
vomiting  had  ceased.  The  production  of  heat 
was  again  taking  place  t  the  urine  began  to  flow; 
and  if  local  disease  did  not  supervene,  the  pheno- 
mena indicated  returning  health  rather  than  a  vio- 
lent conflict  of  nature.  Still  the  recovery  was 
slow  ;  and  the  increasing  fur  on  the  tongue,  the 
morbid  state  of  the  secretions  and  their  gradual 
improvement,  denoted  a  recovery  from  some  se- 
vere convulsion. 

The  varieties  which  have  occurred  in  the  symp- 
toms of  Cholera  in  this  city,  have  been  less  re- 
markable than  such  as  were  noticed  in  Asia.  The 
prominent  features  of  the  disease  have  been  more 
uniform,  though  some  of  them  have  slightly  varied 
from  the  epidemic  of  the  East.  The  collapse  of 
the  features  has  been  less  remarkable  here,  and 
very  frequently  absent ;  and  so  also  has  been  the 
lividnessof  the  countenance,  although  that  was  less 
frequent  in  Asia  than  commonly  supposed.  The 
absence  of  vomiting  or  purging,  or  both  conjointly, 
was  more  frequent  in  the  East,  and  spasms  are 
less  violent  and  more  partial  here,  and  more  easi- 
ly subdued.  I  may  add,  too,  that  our  disease  is 
much  more  fatal. 

The  developement  of  the  constitutional  symp- 
toms is  generally  sudden  here,  as  it  was  in  Asia  ; 

12 


90 


but  it  is  almost  constantly  preceded  by  diarrhoea, 
which  seems  to  be  only  connected  with  the  pre- 
disposition to  the  general  disease,  as  it  may  have 
proceeded  from  a  common  predisposing  cause. 
But  this  diarrhoea  is  evidently  very  often  of  a  more 
artificial  nature,  and  owing  much  to  the  habits  of 
the  individual.  I  have  hitherto  stated  to  you  my 
opinion  of  its  local  character,  and  that  it  is  in  no 
respect  a  symptom  of  Cholera,  till  it  may  have  be- 
come an  exciting  cause  of  the  constitutional  dis- 
ease ;  and  till  then,  that  it  is  susceptible  of  easy 
control.  The  discharges  attendant  on  this  pre- 
liminary state  of  the  bowels  are  generally  different 
from  those  which  are  considered  almost  charac- 
teristic of  Cholera,  and  denote  a  different  mode 
of  action.  They  are  also  usually  coloured  with 
bile,  and  if  they  become  watery,  it  is  a  circum- 
stance which  invariably  attends  common  diarrhoea 
of  considerable  duration.  If  this  preliminary 
diarrhoea,  therefore,  was  rarely  observed  in  the 
East,  its  absence  does  not  affect  the  very  great 
identity  of  the  disease.  It  was  a  prominent 
symptom  of  the  collapsed  Cholera,  and  the  evac- 
uations at  once  exhibited  the  failure  of  the 
bile,  which  is  not  often  noticed  among  us  till 
the  same  general  condition  of  the  system  su- 
pervenes ;  a  circumstance  which  appears  rather 
to  favour  the  belief  of  an  entire  coincidence. 
It  happens,  however,  that  this  premonitory  di- 
arrhoea is  sometimes  complicated  with  an  an- 
tecedent disease,  either  functional  or  organic, 
and  may  be  consecutive  or  accidental.    When  the 


91 


previous  derangement  has  been  merely  function- 
al, it  requires  a  close  investigation  to  determine 
how  much  is  to  be  ascribed  to  the  predisposing 
cause  of  Cholera ;  but  the  history  of  the  case 
may  disclose  some  previous  affection  of  the  di- 
gestive powers, — some  congested  state  of  the 
liver, — or  some  other  derangement  almost  un- 
observed from  its  slow  accession,  but  now  ag- 
gravated by  a  choleric  atmosphere,  and  has  be- 
come the  source  of  some  sympathies,  which  may 
be  mistaken  as  indicative  of  the  predisposition 
that  soon  results  in  Asphyxiated  Cholera.  Again, 
very  nearly  the  same  phenomena  will  proceed 
from  the  malign  constitution  of  the  air,  and  are 
essentially  connected  with  the  formation  of  the 
specific  disease.  An  attention  to  the  case  will 
enable  us  to  distinguish  the  causes  and  the 
nature  of  these  morbid  conditions.  To  con- 
found them  is  sometimes  fatal  to  the  patient, 
and  it  is  better  to  give  them  the  worst  construc- 
tion when  any  doubt  may  remain.  I  have  re- 
peatedly witnessed,  during  the  prevalence  of 
Cholera,  congestions  of  the  liver  and  some  cor- 
responding affection  of  the  mucous  membrane 
of  the  stomach  and  bowels,  which  evidently  pro- 
ceeded from  some  previous  dyspeptic  malady,  or 
from  the  influence  of  hidden  causes,  existing  per- 
haps in  the  atmosphere.  These  cases  have  been 
more  or  less  distinguished  by  a  slow  or  accele- 
rated pulse,  sometimes  slow  and  contracted, 
and  again  full  and  quick  and  frequent,  and  in 
either  case  sometimes  intermittent  or  otherwise 


92 


irregular.  Corresponding  conditions  of  the  skin 
have  been  attendant.  In  the  former  instance,  it 
has  been  cool  and  rather  dry  ;  in  the  latter  warm 
or  hot,  moist  or  husky.  The  urine  has  been  de- 
ficient, red  and  irritating.  The  head  painful,  or 
a  tightness  of  the  brow,  and  soreness  and  stiff- 
ness of  the  eyes.  The  countenance  pale  and 
sallow,  or  flushed  and  inanimate.  The  tongue 
coated  in  various  degrees,  generally  more  exten- 
sively than  in  Cholera,  and  commonly  of  a  yel- 
lowish tinge,  or  a  dirty  white.  The  mouth  rather 
dry  to  the  patient,  and  the  taste  altered.  Inde- 
finite pains  occur  in  the  limbs  and  the  body. 
There  is  often  some  tenderness  and  throbbing  at 
the  region  of  the  stomach,  or  a  sense  of  exhaus- 
tion from  pressing  on  that  organ.  The  appetite 
is  impaired,  and  a  little  food  produces  fulness. 
The  bowels  are  constipated,  and  cathartics  are 
of  slow  and  difficult  operation,  unless  preceded 
by  ample  blood-letting.  The  dejections  are  ra- 
ther black,  or  green,  and  intermixed  with  mu- 
cus ;  or  if  salts,  or  senna,  have  been  given  at  an 
early  period,  the  evacuations  were  watery,  and 
might  be  mistaken  for  rice  water.  The  uniform- 
ity of  temperature  is  often  disturbed,  the  feet 
being  unpleasantly  cold.  Muscular  strength  is 
variously  impaired,  and  the  patient  seeks  rest 
and  retirement.  His  spirits  are  depressed,  and 
he  becomes  impatient  for  relief. 

Such  is  the  most  common  form  of  disease  next 
to  diarrhoea,  that  has  occurred  to  my  observation 
during  the  prevalence  of  Cholera.    It  readily, 


93 


though  slowly,  yields  to  our  remedies,  and  we 
have  therefore  no  opportunity  of  seeing  it  degene- 
rate into  Asphyxia.  It  is  constantly  seen  in  this 
climate,  and  has  not  been  at  any  time  excluded. 
I  am  sensible  it  has  been  regarded  as  a  part  of  the 
reigning  epidemic ;  but  my  conviction  is  opposed 
to  that  opinion.  That  it  may  become  the  exciting 
cause  of  Asphyxiated  Cholera  is  undoubtedly  true  ; 
and  that  symptoms  considerably  analogous  consti- 
tute the  accession  of  that  disease,  I  think  I  have 
sometimes  observed.  They  are,  however,  of  brief 
duration,  and  are  scarcely  known  to  the  physician, 
but  by  information  from  the  friends  or  the  sufferer. 
Collapse  has  supervened,  and  we  commonly  meet 
the  case  presenting  the  phenomena  I  have  de- 
scribed. 

The  symptom  by  which  the  disease  is  most  dis- 
tinguished, and  from  which  it  has  derived  its  spe- 
cific name,  is  invariably  attendant,  and  occurs 
under  the  same  modifications  which  have  been 
noticed  abroad.  The  pulse  generally  becomes 
contracted  and  accelerated  soon  after  the  invasion, 
and  if  the  disease  be  not  complicated  with  pre- 
vious inflammation,  it  is  never  hard.  It  is  espe- 
cially influenced  by  vomiting  and  spasms,  and  by 
sighing,  and  by  voluntary  motion.  It  is  more 
remarkably  depressed  by  the  former  ;  becoming 
even  imperceptible,  as  is  frequently  observed  in 
the  spasms  of  hysteria,  than  increased  in  volume 
by  the  latter.  As  these  causes  cease  to  operate, 
the  pulse  again  resumes  its  character.  Its  fre- 
quency increases  as  the  disease  advances,  and 


94 


there  is  a  corresponding  diminution  of  its  volume. 
These  phenomena,  in  a  majority  of  cases,  go  on 
in  a  progressive  ratio,  till  the  pulse  can  he  no 
longer  distinguished  in  the  extremities.  At  other 
times  it  becomes  irregular,  though  still  frequent, 
and  its  motion  is  often  tremulous,  and  the  pulsa- 
tions cannot  be  counted.  If  the  ear  be  now 
applied  to  the  region  of  the  heart,  its  action  may- 
be found  to  be  perfectly  distinct,  and  not  exceed- 
ing a  hundred  and  thirty  or  forty  pulsations.  This 
want  of  synchronism  is  remarkably  striking  in 
some  subjects,  and  when  it  exists,  the  pulse  some- 
times becomes  obedient  to  the  action  of  the  heart, 
as  the  disease  marches  on.  It  does  not  seem  to 
arise  from  any  accidental  occurrences,  but  is  ob- 
viously a  contingent  symptom  of  the  disease,  and 
I  believe  invariably  a  fatal  one.  Again,  the  pulse 
is  not  remarkably  affected  at  the  invasion,  and 
only  assumes  the  choleric  character  after  a  full 
developement  of  the  other  symptoms.  The  ave- 
rage frequency  of  the  pulsations  from  the  time  of 
the  attack,  and  while  the  pulse  remains  distinct 
in  the  extremities,  is  from  100  to  130.  The  pulse 
is  rarely  intermittent,  as  distinguished  from  irregu- 
lar. It  may  be  commonly  felt  in  a  very  attenuated 
state  till  near  the  extinction  of  life  ;  or  sometimes 
it  wholly  disappears,  and  is  reproduced  by  artifi- 
cial means,  or  returns  without  any  apparent  cause. 
It  had  rarely  happened,  however,  that  the  patient 
lingered  beyond  three  or  four  hours  after  all  pul- 
sation has  ceased  in  the  radial  artery,  until  a 
modified  type  of  the  disease  was  observed  after 


95 


the  first  of  September.    1  had  known  only  two 
parallel  instances  to  those  recorded  by  the  An- 
glo-Asiatics, in  which  death  did  not  supervene 
till  two  or  three  days  after  the  disappearance  of 
the  pulse  ;  in  one  of  which,  the  patient  lingered 
four  days  without  pulsation  at  the  wrist,  and  the 
other,  three  days.    I  have  since  seen  two  simi- 
lar cases,  through  the  politeness  of  Dr.  Lee  ;  in 
one  of  which,  a  very  respectable  lady  of  robust 
health  became  pulseless  soon  after  the  attack  on 
the  6th  of  September,  and  remained  so  for  58 
hours.    The  temperature  of  her  mouth  was  96 
degrees  for  30  hours  after  pulsation  had  ceased. 
She  also  passed  urine  involuntarily  several  times 
during  a  period  of  more  than  38  hours  of  perfect 
Asphyxia.    She  had  no  sweating,  and  her  tongue 
was  nearly  clean,  though  rough  and  rather  florid. 
The  purging  had  been  profuse,  no  vomiting,  nnd 
spasms  very  slight.    Her  skin  was  leaden  and 
warm,  thirst  intense,  and  countenance  anxious. 
The  pulsations  of  the  heart  were  136,  thirty  hours 
after  the  symptoms  of  Asphyxia  had  taken  place. 
During  all  that  period  she  was  perfectly  intelli- 
gent and  very  colloquial,  conversing  in  a  most  in- 
teresting manner.    Her  voice  was  hoarse  and 
unnatural.    Thirty-eight  hours  after  Asphyxia, 
the  temperature  of  her  mouth  stood  at  98  de- 
grees, and  the  pulsations  of  the  heart  were  140. 
At  fifty  hours  the  temperature  was  nearly  the 
same,  body  warm,  extremities  cool,  surface  livid, 
features  not  collapsed,  no  wrinkling  of  the  skin, 
no  sweating,  purging  continuing,  action  of  the 


96 


heart  more  accelerated,  no  sleep  since  Asphyxia, 
sordes  collecting  on  the  teeth,  and  delirium  had 
existed  for  twelve  hours.  Was  still  able  to  jump 
from  her  bed.  Respiration  nearly  natural,  and 
breath  warm.  At  fifty-eight  hours,  respiration 
laborious,  action  of  the  heart  inaudible,  tempe- 
rature of  the  mouth  90  degrees  ;  over  the  entire 
hypochondriac  regions  the  thermometer  stood  at 
106  degrees,  the  temperature  of  the  room  being 
about  74  degrees.  Extremities  cool,  not  cold,  co- 
matose. Skin  of  a  deep  leaden  colour.  Passed 
her  water  at  fifty  hours,  but  whether  afterwards  is 
not  known.  As  late  as  fifty-three  hours  after  the 
cessation  of  the  pulse,  it  required  considerable 
strength  to  confine  her  to  the  bed.  She  died 
twenty  minutes  after  the  last  record  of  her  symp- 
toms. 

The  case  was  treated  principally  by  calomel  and 
Dover's  powder.  Fatigue,  and  a  cathartic  taken 
without  advice,  were  the  exciting  causes. 

I  shall  subjoin  aziother  of  these  remarkable  ex- 
ceptions from  the  ordinary  form  of  Asphyxiated 
Cholera,  which  fell  under  my  observation. 

Mr.  A.,  a  patient  of  Dr.  Lee's,  resided  at  No. 
142  Christopher-street,  a  respectable  butcher  of 
prudent  and  temperate  habits,  aged  about  50  years. 
He  was  seen  byDr.Lee  at  10  o'clock  of  the  morn- 
ing of  the  7th  of  September.  He  had  been  af- 
fected with  diarrhoea  during  the  summer,  and  was 
attacked  with  collapsed  Cholera  on  the  night  of 
the  6th.  The  discharges  suddenly  became  profuse, 
and  were  unattended  with  pain.    There  had  been 


97 


no  vomiting,  nor  did  that  symptom,  or  even  nausea 
take  place  at  any  subsequent  time.    No  chilliness, 
nor  muscular  pain,  nor  much  oppression.  Dr. 
Lee  found  him  without  pulse,  and  the  temperature 
of  his  body  natural.    I  saw  him  first  with  the 
Doctor  at  6  o'clock  on  the  evening  of  the  8th,  at 
which  time  his  symptoms  were  said  to  be  the  same 
as  on  the  morning  of  the  preceding  day.  His 
countenance  denoted  nothing  but  health,  save  a 
vacancy  of  the  eye.    It  was  covered  with  a  natu- 
ral flush,  and  the  cheeks  were  pleasantly  warm. 
A  slight  shade  of  blueness  appeared  on  the  body, 
and  extremities,  which  were  but  little  cooler  than 
natural.    The  fingers  were  assuming  the  square 
form,  but  were  without  wrinkles.     The  veins 
collapsed  and  the  skin  lost  its  elasticity.    No  per- 
spiration, nor  any  unnatural  dryness  of  the  skin. 
Temperature  of  the  body  and  extremities  but  lit- 
tle lower  than  natural.    In  the  mouth  the  ther- 
mometer stood  at  95  degrees.    The  pulse  entirely 
insensible,  and  the  action  of  the  heart  very  feeble  ; 
its  pulsations  92  in  a  minute.   Had  one  slight 
spasm  in  the  leg  the  day  previous.  Passed  his 
urine  frequently  and  freely,  of  a  yellowish  colour 
and  generally  without  volition.    Purging  was  ar- 
rested the  preceding  day,  and  had  scarcely  return- 
ed.   The  dejections  were  watery  and  without 
smell.    No  tenderness  of  the  abdomen,  no  sense 
of  oppression,  but  little  thirst,  drank  moderately, 
but  ad  libitum,  and  without  inconvenience.  Tongue 
moist,  slightly  coated  with  a  whitish  mucus,  and 
rather  pale.  Muscular  strength  considerably  im- 

13 


98 


paired,  and  at  this  time,  he  required  assistance  in 
turning.  Voice  altered  from  the  time  of  the  inva- 
sion, being  hollow  and  feeble.  Spoke  with  effort 
and  reluctance.  Intellect  entire,  but  great  listless- 
ness  and  indifference. 

He  died  at  2  o'clock  on  the  following  night, 
without  any  return  of  purging,  or  any  suffering, 
having  been  without  pulsation  40  hours  from  the 
first  visit  of  his  physician.  Eight  hours  after 
death,  the  temperature  of  his  mouth  was  78  de- 
grees, and  over  the  epigastrium  84,  that  of  the 
room  being  72  degrees.  His  skin  was  not  livid, 
and  there  was  still  a  slight  flush  of  the  face. 

Calomel  was  the  principal  remedy. 

After  the  1st  of  September  the  Cholera  again 
extended  and  increased  in  malignancy  ;  I  had  at 
no  time  known  it  to  present  a  more  formidable 
aspect,  and  it  has  occurred  in  many  instances 
without  any  "  premonitory  symptoms,"  and 
sometimes  without  any  apparent  exciting  cause. 
From  that  period,  I  have  seen  the  pulse  extin- 
guished, in  many  cases,  at  the  very  invasion,  and 
not  again  returning,  the  patients  expiring  in  four 
to  twelve  hours  after. 

The  superficial  veins  are  flattened  from  an  ear- 
ly period,  and  the  blood,  which  flows  from  them 
in  bleeding,  seems  not  to  be  restored,  or  but  very 
gradually.  Hence  it  is  nearly  impossible  to  ob- 
tain much  blood,  in  this  manner,  from  a  collap- 
sed subject.  It  runs  freely  for  a  short  time  only 
from  the  temporal  artery,  and  is  obtained  with 
great  difficulty  by  cupping  and  leeching.  In 


99 


Asia  large  quantities  of  blood  were  often  ab- 
stracted from  the  veins  of  collapsed  subjects, 
but  always  with  difficulty.  This  symptom  will 
not  affect  the  identity  of  the  disease,  if  we  ad- 
vert to  the  far  greater  integrity  of  the  blood  in 
the  East ;  and  the  infrequency  of  premonitory 
diarrhoea.  It  is  always  particularly  dark  from  the 
veins,  and  in  consistence  more  than  naturally 
thick.  These  phenoniena  are  observed  to  in- 
crease as  the  disease  advances,  and,  I  believe, 
they  are  uniformly  present.  I  have  heard  of  no 
instance  in  which  the  blood  flowed  readily,  or  in 
which  it  was  not  in  some  degree  discoloured,  at 
whatever  period  abstracted.  It  has  very  gene- 
rally happened  that  the  blood  has  coagulated 
slowly  and  imperfectly,  and  often  not  separating 
into  its  component  parts,  unless  drawn  into  a 
vessel  best  adapted  to  promote  that  investigation. 
The  coagulation,  however,  will  be  soonest  and 
most  perfect  as  the  blood  may  have  been  abstract- 
ed near  the  time  of  the  invasion,  and  it  is  liable 
to  be  influenced  by  previous  diarrhoea,  &c.  It  is 
deprived  of  its  serum  in  proportion  to  the  duration 
of  the  disease,  and  the  premonitory  diarrhoea, 
and  this  appearance  occurs  where  the  purging 
and  vomiting  may  have  been  very  slight.  In  those 
cases  the  watery  portion  had  escaped  by  the  skin, 
from  which  the  perspiration  runs  almost  in  a 
current.  However  carefully  abstracted,  there  is 
no  buffiness,  or  scarcely  a  pellicle  of  lymph  on 
the  surface.  In  the  East,  the  blood  coagulated 
quickly,  and  the  difference  is  easily  explained 


100 


without  affecting  the  identity  of  the  disease.  The 
evacuations  were  less  profuse,  and  there  having 
been  little  of  our  antecedent  diarrhoea,  the  blood 
was  less  exhausted  of  its  serum,  and  some  other 
component  parts, — a  circumstance  which  must 
materially  affect  the  sensible  phenomena  of  that 
fluid.  Thus,  too,  is  explained  the  greater  success 
which  the  Asiatics  derived  from  blood-lettings 
than  has  been  enjoyed  in  Europe  or  America. 
The  remedy  was  there  applied  before  the 
blood  was  bereft  of  all  but  its  crassa- 
mentum,  which  has  been  with  us  but  the  poor 
remnant  on  which  despair  has  sometimes  seiz- 
ed ;  or  if  in  a  few  solitary  cases,  the  fluids 
have  yet  remained  in  the  system,  and  some 
determined  hand,  well  directed  by  the  lights 
of  science,  has  promptly  liberated  the  cir- 
culation, it  exemplifies  the  feeble  assistance 
which  is  afforded  by  nature  when  she  has  thrown 
off  the  principles  of  the  blood,  and  affords  ano- 
ther analogy  between  our  own  and  the  Eastern 
epidemic.  In  these  rare  cases,  I  am  told,  what 
might  have  been  expected,  that  the  blood  soon 
becomes  more  florid,  and  flows  more  and  more 
freely. 

The  colour  of  the  blood  does  not  appear  to  be 
much  influenced  by  the  manner  in  which  respi- 
ration is  performed.  The  mechanical  part  of 
this  function  often  appears  to  go  on  well  after 
pulsation  has  ceased,  and  the  skin  become  livid. 
Neither  do  the  secretions  affect  the  colour,  which 
appears  to  depend  on  the  period  of  the  collapse. 


iOl 

I  cannot  doubt,  that  the  colour  results  in  a  great 
degree  from  some  interruption  in  the  organic  func- 
tions of  the  lungs,  and  to  which  I  adverted  in  a 
former  letter. 

Dr.  Gale,  who  kindly  favoured  me  some  time 
since  with  a  few  results  of  his  experiments  on 
the  blood,  and  which  are  noticed  in  one  of  my 
former  letters,  has  more  recently  detected  the 
existence  of  an  oil  in  a  free  state  in  every  part 
of  the  vascular  system,  and  which  I  have  since 
had  opportunities  of  witnessing  in  dissections. 
It  is  sometimes  very  conspicuous,  and  resembles 
olive  oil.  It  abounds  most  as  the  patient  ap- 
proaches death. 

The  difficulty  with  which  the  blood  is  abstract- 
ed from  the  veins  is  never  owing,  directly,  to  its 
thickness,  but  to  the  interruption  in  the  circular 
tion.  Its  consistence,  although  obviously  increas- 
ed, has  probably  been  overrated  by  authors. 

The  varieties  which  occur  in  the  Purging  are 
not  numerous.  Notwithstanding  this  evacuation 
has  been  abundant  during  the  antecedent  diar- 
rhoea, it  becomes  still  more  profuse  when  Cho- 
lera is  developed.  The  quantity  is  sometimes 
surprisingly  large,  amounting  to  more  than  fif- 
teen quarts  in  twelve  hours.  This  is  probably 
the  largest  estimate,  and  in  such  instances  there 
has  been  comparatively  little  vomiting  or  perspi- 
ration. Some  rare  cases  have  occurred  in  which 
this  symptom  and  vomiting  have  been  absent. 
The  discharge  takes  place  without  much,  if  any, 
pain,  and  is  unattended  with  effort.    In  a  plu- 


102 


rality  of  cases  it  occurs  without  volition,  after  col- 
lapse is  fully  formed,  and  does  not  attract  the 
notice  of  the  patient,  though  at  an  earlier  pe- 
riod the  impulse  may  have  been  strongly  and  ir- 
resistbly  felt.  The  fluid  is  ejected  very  various- 
ly, often  with  violence,  rarely  appearing  like  the 
action  of  cathartics.  The  patient  sits  for  a 
moment  on  the  pan,  and  we  are  astonished  when 
he  rises,  to  observe  the  quantity  discharged. 
Again  it  runs  away  slowly,  or  there  is  merely  an 
oozing.  It  is  attended  by  an  expression  of  great 
exhaustion,  and  is  felt  by  the  pulse.  It  con- 
tinues, if  not  arrested  by  art,  till  near  the  close 
of  life.  The  sensible  properties  of  the  fluid  eva- 
cuated are  such,  almost  uniformly,  as  I  have 
described.  Sometimes  it  resembles  dirty  water, 
and  more  rarely  presents  a  bluish  appearance. 
It  occasionally  exhibits  more  of  a  milkiness,  than 
of  the  rice  water  ;  but  in  that  case  a  precipitate 
takes  place,  and  leaves  a  colourless  serum.  I 
have  seen  two  fatal  instances  in  which  a  deep 
greenish  yellow  bile  was  vomited  and  purged 
till  near  the  extinction  of  life.  The  surface  was 
livid  and  the  pulse  as  usual  in  Cholera.  They 
are  very  rare  exceptions.  In  a  few  instances  at 
the  hospitals,  there  has  been  seen  the  red- 
dish appearance  like  the  washings  of  beef,  as 
described  by  authors.  In  these  cases  there  is 
more  abdominal  sufl'ering.  The  discharges  from 
the  stomach  and  bowels  are  nearly  alike.  The 
dejections  are  generally  inodorous,  but  are 
very  rarely  attended  by  a  strong  and  ofiensive 


103 


ssmell.  Excessive  discharges  constitute  a  hope- 
less case,  and  the  most  malignant  have  been 
now  and  then  unattended  by  any.  They  are 
generally  easily  arrested  by  appropriate  means, 
and  consequently  it  does  not  long  remain  a  symp- 
tom after  medical  treatment  is  applied.  From 
the  abundance  of  fluid,  however,  which  is  fre- 
quently found  in  the  canal,  I  have  no  doubt  that 
the  secretion  often  goes  on,  notwithstanding  its  dis- 
charge has  been  arrested,  and  continues  to  exert  an 
influence  on  some  of  the  other  phenomena.  The 
discharges  are  occasionally  the  obvious  result  of 
affections  of  the  mind.  Fear,  particularly,will  sud- 
denly excite  profuse  evacuations ;  but  how  far 
its  action  extends  to  the  organic  functions  is 
doubtful.  The  secretion  may  have  been  already 
produced,  and  the  muscles  alone  have  felt  the 
impulse.  It  need  not  be  said  that  purging  is  an 
earlier  symptom,  and  is  entirely  more  excessive 
and  uniform  than  vomiting.  I  do  not  know  that 
it  has  ever  been  absent  where  vomiting  has  ap- 
peared. 

In  India  this  symptom  occurred  only  during 
the  collapse  ;  it  was  then  excessive  and  of  short 
duration.  In  New-York  diarrhoea  has  generally 
pursued  the  patient  for  some  hours  or  days,  be- 
fore the  constitutional  disease  is  developed  ;  then 
becoming  even  more  severe  than  at  the  East,  and 
continuing  with  greater  pertinacity  until  arrested 
by  art. 

Vomiting  is  comparatively  infrequent  with  the 
purging,  but  occurs  early  among  the  symptoms 
of  collapse.     It  often  subsides  spontaneously; 


104 


especially  if  the  stomach  be  not  irritated  by  drink. 
It  aggravates  the  thirst,  but  is  not  connected  with 
its  production,  so  that  no  relief  can  be  obtained 
from  fluids.  The  ejection  is  not  attended  with 
much  pain,  but  is  often  effected  with  severe  efforts. 
The  ingesta,  however,  are  not  always  entirely 
thrown  off.  It  never  occurs  without  purging, 
and  is  much  more  easily  arrested.  It  is  always 
aggravated  by  cold  or  hot  drinks,  unless  in  very 
small  quantities,  and  affections  of  the  mind  will 
produce  it.  It  is  also  protracted  and  rendered 
more  obstinate  by  emetics.  It  is  very  frequently 
wanting,  and  cannot  be  regarded  as  a  severe 
symptom  of  the  disease.  I  know  not  that  the 
case  is  more  favourable  from  its  absence.  The 
fluid  is  sometimes  discharged  in  large  quantities, 
and  generally  resembles  the  dejections.  Again 
it  is  in  small  quantities,  and  thrown  up  with 
greater  effort,  being  more  like  the  natural  mucus 
of  the  stomach.  It  is  not  infrequently  tinged 
with  green,  sometimes  bluish  and  very  rarely  yel- 
low. I  have  seen  it  ejected  in  large  quantities 
of  a  deep  greenish  yellow,  when  the  patients 
were  far  advanced  in  the  worst  varieties  of  col- 
lapse. The  exhaustion  from  vomiting  is  greater, 
but  less  permanent  and  extensive  than  from 
purging.  It  does  not  appear  to  aflfect  the  state 
of  the  skin  in  respect  to  perspiration.  It  seems 
not  to  be  influenced  by  temperament,  or  sex,  but 
is  evidently  more  connected  with  the  habits  of  the 
individual.  I  have  seen  it  occurring  during  the 
violence  of  the  epidemic,  as  a  symptom  of  our 


105 


indigenous  cholera  morbus.  It  was  then  more 
obstinate,  and  attended  with  bilious  discharges. 
The  diseases  presented  striking  dissimilarities. 

The  most  remarkable  condition  of  the  skin  is 
the  impaired  state  of  its  irritability,  while  its 
sensibility  is  not  much  diminished.  Simple  irri- 
tants, however  active,  do  not  produce  their  ordi- 
nary effect.  Cantharides,  ammonia,  &c.  are  per- 
fectly powerless,  and  the  chemist  is  consulted  for 
combinations  that  shall  evolve  more  active  prin- 
ciples. These,  too,  fail  in  their  turn,  and  we 
resort  to  fire  and  boiling  water  as  the  last  resource 
of  art.  But  the  patient  will  not  even  always  burn 
— save  in  his  sensibility,  which  pleads  as  piteously 
as  in  the  fulness  of  health.  The  mustard  cata- 
plasm soon  becomes  a  source  of  great  annoyance, 
and  Rhinelander's  ointment  sometimes  produces 
expressions  of  great  suffering.  Still  the  marble 
coldness  remains,  and  vascular  action  is  as  dead 
as  ever.  There  is  something  characteristically 
striking  in  this  state  of  the  temperature.  It  is 
the  coldness  of  death,  and  if  the  skin  be  wet  with 
perspiration,  a  chill  is  imparted  to  the  touch. 
This  absence  of  heat  is  often  confined  to  the 
extremities  and  face,  though  generally  exist- 
ing in  an  inferior  degree  over  the  greater  part 
of  the  body.  It  is  frequently  preternaturally  great 
at  the  scrobiculus  cordis,  where  I  have  found  it 
accumulated  in  a  dying  choleric  at  106  degrees. 
I  am  informed  that  in  two  cases  at  the  Greenwich 
Hospital,  the  heat  of  the  skin  was  almost  natural  till 
death.  In  those  instances  the  pulse  was  very  indis- 

14 


106 


tinct  during  collapse,  and  there  was  no  sweating^ 
In  the  case  of  the  lady  to  which  I  have  alluded,  the 
temperature  of  the  whole  body  was  preserved  with- 
out a  parallel.  I  have  never  remarked  an  increase 
of  the  temperature  as  the  extinction  of  life  ap- 
proaches, excepting  at  the  region  of  the  epigas- 
trium ;  where  it  sometimes  acquires  a  great  exal- 
tation just  before  death  ;  but  after  death  the  general 
surface  often  becomes  warmer.  I  ascribe  this 
circumstance,  not  to  the  production  of  heat,  but  to 
the  cessation  of  the  vital  laws,  which  enables  those 
that  govern  dead  matter  to  operate,  and  to  equalize 
the  caloric  already  existing.  The  coldness  of  the 
skin  is  increased  by  sweating,  but  is  less  so  than 
would  be  inferred,  d  priori.  It  is  also  increased 
by  purging,  but  not  in  a  remarkable  degree.  In 
adverting  again  to  the  loss  of  irritability,  we  are 
sometimes  astonished  that  boiling  water  will  pro- 
duce no  vesication,  when  it  is  known  to  vesicate 
other  subjects  if  applied  immediately  after  death* 
It  would  be  folly  to  contend  that  the  living  man 
is  more  dead,  than  he  who  is  defunct  beyond  all 
question.  This  phenomenon  can  be  only  explained 
by  recognising  a  peculiar  morbid  condition  of  the 
skin,  in  which  its  organic  properties  are  so  changed, 
that  they  have  entirely  lost  their  natural  suscepti- 
bilities ;  and  it  is  another  argument  against  the 
principle  of  sympathy,  and  in  behalf  of  constitu- 
tional disease. 

Siceating  has  been  a  very  variable  symptom; 
At  the  irruption  of  the  epidemic,  it  was  most  uni- 
versal, and  became  less  uniform  after  its  decline* 


10? 


From  the  1st  of  September  it  was  absent  in  a  ma- 
jority of  cases,  and  less  frequently  attended  those 
subjects  who  were  pulseless  from  the  attack.  lb 
occurred  in  various  degrees,  from  the  most  profuse, 
to  an  insensible  transpiration,  the  skin  being  rarely 
preternaturally  dry.  It  was  always  cold,  and  ra- 
ther clammy ;  but  in  subjects  transfused,  it  was 
suddenly  increased  in  quantity,  and  its  tempera- 
ture exalted  to  a  hundred  degrees.  Its  odour  was 
strong,  and  so  very  characteristic,  that  the  disease 
could  be  known  by  the  smell.  It  was  most  abun- 
dant when  purging  was  least,  but  they  occurred 
in  connexion  to  an  excessive  degree. 

The  skin,  in  all  subjects,  lost  its  elasticity^  and  if 
pinched,  would  slowly  resume  its  former  condition. 
A  remarkable  appearance  was  its  corrugation  and 
folds  on  the  fingers  and  toes.  It  occurred  under 
every  aspect  of  the  disease,  and  was  more  or  less 
present  in  a  great  majority  of  cases.  It  was  seen 
in  subjects  where  purging  and  sweating  were  not 
severe,  but  most  so,  where  the  latter  was  excessive, 
and  it  often  happened  in  the  entire  absence  of 
sensible  perspiration.  It  was  less  conspicuous  on 
the  toes  than  the  fingers,  and  often  involved  the 
entire  hands  and  feet.  A  flattening  of  the  four 
sides  of  the  fingers  was  first  observed,  producing 
a  squareness  of  shape.  The  folds  then  succeed- 
ed, longitudinally  on  the  front  and  sides,  and 
tranversely  on  the  back  ;  and  if  they  became  nu- 
merous and  large,  the  squareness  of  the  fingers 
became  less  distinct.  If  sweating  were  profuse, 
the  fingers  and  toes  were  greatly  reduced  in  size, 


108 


and  the  skin  was  remarkably  corrugated.  This 
corrugation  appeared  to  arise  from  three  causes ; 
in  part  from  the  direct  morbid  action  of  the  skin, 
from  sweating,  and  from  other  evacuations.  The 
limbs  did  not  exhibit  an  appearance  of  emaciation. 

The  colour  of  the  skin  was  less  uniform  than 
many  other  symptoms,  but  was  affected  in  a  ma- 
jority of  subjects.  The  prevailing  hue  was  leaden, 
and  like  other  varieties,  increased  with  the  pro- 
gress of  the  disease.    It  was  not  commonly  most 
obvious  about  the  eye,  as  has  been  elsewhere  no- 
ticed, but  existed  in  an  unvarying  shade  over  the 
surface.   If  there  were  congeries  of  varicose  veins, 
they  exhibited  dark  patches.  This  tint,  more  than 
any  other,  increased  the  cadaverous  expression. 
Next  in  frequency  were  various  shades  of  blue- 
ness,  and  this  occurred  in  most  instances  of  sweat- 
ing, the  leaden  colour  being  more  peculiar  to  a 
dryer  state  of  the  skin.    It  abounded  most  on  the 
nails,  hands,  feet  and  face,  particularly  the  lips, 
but  did  not  especially  exist  around  the  eyes.  It 
was  also  diffused  in  a  lighter  shade  over  the  bo- 
dy, and  was  remarkable  on  the  contracted  scro- 
tum.    When  the  sweating  was  excessive,  the 
hands  would  sometimes  lose  the  colour  and  be- 
come blanched,  especially  the  palms,  the  nails 
remaining  blue.   A  still  darker  hue  was  frequent- 
ly observed,  occurring  on  the  body  and  limbs  ia 
large  and  small  patches,  and  covering  the  face  en- 
tirely or  partially.    It  would  sometimes  recede, 
and  again  appear,  and  was  often  influenced  by  the 
spasms.     It   would  sometimes  subside  before 


109 


death,  and  return  in  a  short  time  after  ;  or  it  would 
disappear  soon  after  death,  and  reappear  on  the 
upright  part  of  the  body  within  an  hour  or  two. 
A  still  darker  hue,  approaching  the  African  colour, 
was  more  rare  and  owing  to  extravasated  blood. 
I  have  seen  it  covering  nearly  ihe  entire  surface  of 
the  body. — It  was  connected  with  cases  of  great 
malignancy,  and  in  which  the  spasms  were  violent. 
A  deep  brown  and  a  leaden  colour  frequently  oc- 
curred around  the  eyes,  but  when  it  was  distinct 
there,  it  was  scarcely  observed  on  the  face.  In  a 
large  proportion  of  cases,  there  was  no  striking 
change  of  colour,  and  in  some  instances  of  most 
perfect  Asphyxia,  the  countenance  was  florid  as 
in  health.  The  nails  were  often  curved,  when  the 
fingers  were  much  shriveled. 

The  countenance  of  a  choleric  can  seldom  be 
mistaken,  notwithstanding  the  variety  by  which  it 
is  distinguished.  It  is  not,  however,  generally,  the 
cholera  countenance  of  the  Asiatics  ;  and  perhaps 
in  no  feature  of  the  disease  does  there  exist  a 
greater  disparity.  At  the  irruption  of  the  epidemic 
I  saw  many  cases  presenting  the  true  collapsed, 
shrunken  features,  described  by  oriental  writers, 
but  they  have  been  less  common  since.  They 
were  attended  by  the  whole  array  of  the  worst 
symptoms.  In  most  instances  there  occurs  some 
sinking  of  the  features,  particularly  of  the  eyes,  the 
expression  of  which  is  differently  affected,  being 
generally  dull,  and  very  rarely  presenting  the  dim 
and  opaque  appearance  that  was  so  constantly 
noticed  in  the  East.    This  organ  is  fixed,  and 


110 


moves  only  when  excited  by  some  mental  or 
physical  impression  ;  but  seems  as  ever  sensible 
to  the  light,  of  which  the  patient  sometimes  com- 
plains. There  is  scarcely  any  winking,  and  thus 
far  the  combination  represents  the  inanimate  statue, 
which  derives  further  effect  from  the  stillness  of 
all  the  facial  muscles.  If  the  patient  sleep,  it  is 
with  his  eyes  nearly  open,  and  the  lips  parted. 
Sometimes  the  eye  acquires  an  unnatural  lustre, 
but  with  the  same  appearance  of  vacuity  ;  and  this 
will  remain  a  very  striking  object  for  two  or  three 
hours  after  death, — slowly  fading  away.  Such 
cases  are  attended  by  severe  spasms.  The  pupil 
exhibits  every  variety  of  contraction  and  dilatation- 
Petechiae  sometimes  appear  on  the  sclerotic  coat. 
I  have  never  seen  the  "  cornea  apparently  covered 
with  a  film," 

In  a  majority  of  subjects  the  cheeks  are  rather 
moderately  sunken  than  collapsed, — rarely  as  much 
so  as  in  bad  cases  of  cholera  morbus.  The  nose 
is  more  pinched,  and  especially  so  when  the  ala? 
are  concerned  in  the  respiration. 

Again,  there  is  scarcely  a  perceptible  sinking  of 
any  of  the  features.  They  are,  however,  all  quiet, 
and  the  inanimate  eye  is  sufficiently  characteristic. 
Rarely,  there  is  a  natural  flush,  and  an  expression 
of  health,  and  nothing  to  denote  the  near  extinc- 
tion of  life,  save  the  never  failing  spiritless  eye. 
The  expression  evidently  depends  in  a  degree  on 
the  intellect  and  habits  of  the  individual. 

A  particular  coincidence  has  occurred  between 
the  spasmodic  affections  of  our  cholera  subjects 


Ill 


and  those  of  the  East.    It  is  with  us,  however,  a 
more  common  symptom,  existing  in  at  least  three 
fourths  of  the  cases;  Of  all  the  symptoms  it  seems 
to  denote  more  than  any  other  a  primary  impres- 
sion of  the  morbific  agent  on  the  nervous  system, 
and  that  its  influence  is  thus,  in  part  at  least,  pro- 
pagated to  other  organs.    It  is,  however,  but  an 
isolated  evidence,  and  rests  on  its  frequent  occur- 
rence as  an  early  symptom  of  Cholera,  and  the 
fact  that  it  existed  merely  as  a  symptom  in  many 
people  in   the  enjoyment  of  health,  especially 
during  the  increase  of  the  epidemic.    It  was  some- 
times late  in  its  appearance,  and  was  entirely  most 
violent,  where  the  purging  and  vomiting  were 
most  severe.    It  was  most  so  in  the  robust,  espe- 
cially if  intemperate, — and  more  so  in  males  than 
females.    In  children  it  was  rare  or  slight.  It 
was  generally  confined  to  the  voluntary  muscles^ 
though  it  aflected  those  of  a  mixed  nature.  It 
was  sometimes  detected  in  the  muscular  coat  of 
the    large  intestines    after  death,  which  were 
found  greatly  contracted.     In  those  cases  the 
voluntary  muscles  were  also  affected.  The  muscles 
of  the  feet  and  toes,  and  the  gastrocnemii,  were 
the  first  in  order  of  frequency,  and  next  those  of 
the  hands  and  fingers.    Then  follow  those  of  the 
arm.s  and  thighs,  from  which  the  spasms  extend 
to  the  abdomen  and  more  rarely  to  the  chest.  The 
diaphragm  appears  to  be  often  affected  with  tonic 
spasm,  from  the  manner  in  which  the  thoracic 
muscles  become  interested  in  respiration  ;  it  is 
rarely,  if  ever,  aflected  with  the  clonic  variety,  and 


112 


I  have  never  witnessed  an  instance  of  hiccough  of 
more  than  momentary  duration.    The  contrac- 
tions of  the  diaphragm  are  attended  with  distress, 
not  with  pain.   The  fingers  and  toes  are  distorted  in 
every  direction,and  the  limbs  are  sometimes  thrown 
aboutwith  considerable  violence.  Then  again  this 
species  of  spasm  suddenly  subsides  to  the  fixed 
contraction,  or  they  exist  in  connexion, even  aflfect- 
ing  parts  of  the  same  muscle  at  the  same  moment. 
This  coincidence  I  have  particularly  noticed  in 
the  gastrocnemii.    The  muscles  of  the  abdomen 
are  chiefly  aflfected  with  the  tonic  spasm,  by  which 
theparieties  are  brought  into  permanent  contact, 
and  a  singular  hardness  is  the  characteristic  re- 
sult.   The  body  is  rarely  distorted  in  conse- 
quence, but  occasionally  the  clonic  spasm  dou- 
bles the  sufferer.    The  muscles  of  the  eye,  I  be- 
lieve, are  never  aflfected,  at  least  with  the  clonic 
species,  nor  those  of  the  eyelids,  and  very  rarely 
the  facial  muscles.    Those  of  the  neck  are  more 
liable  to  convulsive  twitchings.    The  thoracic 
and  abdominal  muscles  were  sometimes  aflfected, 
in  connexion,  with  tonic  spasm.  The  bladder  was 
evidently  rigidly  contracted  in  most  subjects, 
which  appeared  to  be  rather  the  result  of  spasm, 
than  its  natural  tendency  to  contract. 

The  greatest  suflfering  attended  the  contrac- 
tions of  the  simple  voluntary  muscles,  especially 
the  gastrocnemii,  in  which  the  pain  was  gene- 
rally very  great ;  evincing  rather  an  exaltation 
than  "  diminution  of  nervous  power."  The  af- 
fection of  these  muscles  was  very  similar  to  that 


113 


which  occurs  in  hysteria  ; — rarely,  if  ever,  like 
the  movements  in  convulsions  or  epilepsy.  There 
was  no  pain,  but  sometimes  distress,  attending 
the  tonic  spasm  of  the  muscles  of  a  compound 
nature.  I  am  not  informed  whether  there  was 
any  unusual  suffering  in  the  abdomen  of  the  few 
in  whom  the  large  intestine  was  found  contracted. 
Affections  of  the  mind  not  infrequently  excited 
the  spasms. 

This  species  of  suffering  would  often  produce 
great  jactation,  and  the  patient  would  even  start 
from  his  bed  in  pursuit  of  relief. 

Respiration  was  less  laborious,  than  would  be 
inferred  from  the  embarrassed  circulation  in  the 
lungs,  the  action  of  the  heart,  and  the  tonic  spasm 
which  frequently  seized  some  of  the  muscles  con- 
cerned in  the  process.     Whenever  the  spasm 
attacked  the  abdominal  muscles,  it  was  obvious 
from  the  great  labour  of  the  others  ;  and  if  the 
diaphragm  became  its  subject,  it  was  denoted  by 
a  great  elevation  of  the  chest,  and  the  action  of 
the  alse  of  the  nose  ;  and  again  the  abdominal 
muscles  especially  participated.    These  varieties 
were  frequently  presented  and  were  well  marked. 
This  function  was  generally  slowly  performed,  and 
sometimes  particularly  so, — especially  if  there  ex- 
isted a  determination  to  the  brains    It  was  rarely 
attended  by  great  distress,  though  it  was  fre- 
quently apparent  that  the  patient  was  oppressed  ; 
a  sensation  next  to  thirst  that  created  the  great- 
est restlessness.    The  patient  would  lie  for  a  short 
time  in  a  state  of  apparent  ease  and  abstraction, — 
then  suddenly  turn  with  a  sigh,  or  a  moan,  throw- 

15 


114 


ing  the  covering  from  him,  and  was  again  at  rest 
till  the  same  process  was  repeated.  The  admis- 
sion of  fresh  air  relieved  the  jactation.  The 
breath  became  cool  at  an  uncertain  period  of  the 
disease.  It  was  almost  a  uniform  and  striking 
symptom. 

The  Voice  was  affected  in  most  of  the  subjects ; 
but  its  tone  was  variously  modified.  In  some  it 
was  hollow  and  sepulchral, — in  others  it  became 
flat,  and  oppressed,  and  again  it  was  a  whisper, 
or  it  was  quite  inaudible.  At  other  times  it  was 
hoarse  and  rough,  and  in  a  few  it  continued  natu- 
ral. The  patient  generally  spoke  with  effort,  but 
was  sometimes  very  colloquial.  I  have  only  re- 
marked a  disposition  to  converse  in  the  intelligent 
and  well  informed  ;  and  in  those  instances,  speak- 
ing did  not  appear  to  produce  exhaustion  ;  and 
was  performed  without  difficulty  when  the  voice 
was  distinctly  audible. 

I  have  formerly  remarked,  that  no  indication 
could  be  derived  from  the  state  of  the  tongue. 
If  premonitory  diarrhoea  had  existed,  in  a  majority 
of  instances  the  tongue  was  coated  in  the  centre 
of  a  dirty  white,  and  clean  at  the  tip  and  edges. 
In  other  cases  this  coating  was  more  extended, 
superficial  and  lighter.  Again,  it  was  merely  a 
sliminess  which  was  easily  detached,  and  soon 
returned.  When  presenting  any  of  these  condi- 
tions, the  coating  has  been  more  dense  and  ex- 
tensive during  the  existence  of  the  antecedent 
diarrhoea, — the  irruption  of  Cholera  so  modifying 
the  action  as  to  change  the  aspect  of  this  con- 
dition of  the  organ ;  and  it  often  continued  de- 


115 


creasing  during  the  progress  of  the  disease. 
Under  these  circumstances  the  colour  of  the 
tongue  was  paler  than  natural,  and  the  mouth 
was  moist.  In  other  instances  a  slight  frosting 
appeared,  like  minute  particles  of  sugar,  through 
which  a  more  florid  and  dryer  tongue  might  be 
every  where  seen .  Again  there  was  only  a  rough- 
ness of  the  surface,  resembling  a  coarse  file, 
when  the  tongue  was  also  florid  and  deficient  in 
moisture.  Or  it  was  perfectly  smooth  and  red- 
dish and  moist,  presenting  the  aspect  of  beef ; 
or  it  was  clean  and  livid  ;  or  it  might  be  in  every 
respect  perfectly  natural.  I  never  saw  it  coated 
to  any  remarkable  extent,  and  should  consider 
a  dense  coating  favourable.  It  approached  its 
natural  character  most  in  those  subjects  who 
had  been  attacked  without  the  common  premo- 
nitions, and  was  always  formidable.  The  mouth 
was  almost  constantly  moist,  though  sometimes 
approaching  a  state  of  dryness.  A  dark  sordes 
would  often  accumulate  about  the  teeth  just  be- 
fore death. 

There  was  no  symptom  attending  the  tongue 
and  mouth  so  uniform  as  the  reduction  of  heat, 
and  which  I  believe  always  occurred  for  some 
time  before  dissolution.  I  had  always  a  ther- 
mometer with  me,  and  applied  it  in  a  great  num- 
ber of  cases,  being  careful  that  the  patient  had 
not  drunk  just  previously.  It  was  also  an  early 
symptom,  and  while  pulsation  existed  in  the  ra- 
dial artery  it  averaged  about  92  degrees.  Soon 
after  the  invasion  it  descended  to  96,  and  pro- 
gressively sunk  to  86  or  88  degrees,  when  life 


116 


became  extinct.  The  lowest  temperatui*e  I  have 
observed  was  81  degrees,  in  a  dying  subject.  I 
have  frequently  found  it  85,  near  the  extinction 
of  life,  particularly  in  protracted  cases.  In  one 
instance,  in  which  the  disease  attacked  without 
any  premonitory  symptoms,  I  found  the  tempe- 
rature in  six  hours  after  at  84  degrees,  and  pulsa- 
tion still  existed ;  and  in  another,  under  exactly 
the  same  circumstances,  it  stood  at  86. 

At  94  degrees  it  became  what  is  called  a 
"  choleric  tongue,"  and  was  sensibly  cold  to  the 
touch.  At  this  temperature,  also,  the  breath  im- 
parted a  feeling  of  coldness,  and  injections  came 
away  with  the  same  property.  The  accumulated 
heat  at  the  epigastric,  or  the  hypochondriac,  re- 
gion, did  not  affect  the  temperature  of  the  mouth 
or  the  bowels.  As  it  augmented  in  one,  it  di- 
minished in  a  corresponding  ratio  in  the  other: 
These  phenomena,  and  the  coldness  of  the 
breath,  contrasted  surprisingly  with  the  intensity 
of  the  thirst;  but  that  I  apprehend  was  owing  to 
the  morbid  state  of  the  stomach.  I  do  not  as- 
cribe it  to  the  accumulated  heat  around  that  organ, 
where  I  doubt  not  it  existed  within  the  cavity  of 
the  abdomen,  in  some  instances  at  more  than  112 
degrees.  I  once  examined  a  subject  with  Dr. 
Ludlow  in  15  or  20  minutes  after  death,  in  which 
I  have  no  doubt  that  temperature  existed,  as  I 
think  also,  it  must  in  the  dying  patient  in  whom  1 
found  the  heat  on  the  surface  at  106  degrees. 
Neither  do  I  believe  the  sense  of  heat  or  burning 
in  the  region  of  the  stomach  is  connected  with 


117 

this  exalted  temperature.  It  is  not  a  common 
complaint,  and  I  have  heard  it  equally  made^ 
when  the  surface  of  the  epigastrium  was  cool. 
The  patient  was  never  disturbed  by  the  intro- 
duction of  the  thermometer  into  his  mouth,  but 
would  generally  contribute  some  assistance. 

The  Glandular  Seeretions  have  been  suspend- 
ed in  the  same  remarkable  manner  that  has  been 
every  where  observed ;  particularly  of  those  organs 
which  are  most  concerned  in  the  functions  of  life. 
I  have  generally  found  scarcely  a  trace  of  bile  in 
the  liver,  and  the  vesicle  containing  about  the 
quantity  which  we  find  in  subjects  of  other  dis- 
eases. The  same  extinction  of  this  function  of 
the  liver  is  equally  denoted  by  the  absence  of  bile 
in  the  discharges,  with  the  few  exceptions  of 
which  I  have  formerly  spoken.  When  bile  has 
been  discharged  during  the  progress  of  fatal  col- 
lapse, it  has  exhibited  a  greenish  appearance  with 
a  tinge  of  yellow,  and  has  existed  in  abundance 
and  without  smell.  There  was  no  urine  secreted 
in  these  cases.  They  were  as  malignant  as  the 
majority. 

I  have  only  seen  two  cases  in  which  the  urine 
was  passed  during  a  protracted  collapse,  and  in 
which  the  patients  were  pulseless  from  the  be- 
ginning. These  cases  occurred  in  the  private 
practice  of  Dr.  Lee,  and  are  the  two  to  which  I 
have  before  adverted.  It  was  a  very  rare  at- 
tendant. 

I  now  approach  the  condition  of  those  organs 
which  are  especially  connected  with  the  great 


nervous  system,  and  in  which  we  should  expect 
to  find  the  most  indisputable  evidence  of  disease, 
did  it  consist  in  a  "  prostration  of  nervous  ener- 
gy," The  great  centre  itself  of  sensibility  gives 
no  token  that  its  energy  is  much  impaired  ;  but 
in  presenting  you  with  a  faithful  account  of  the 
varieties  which  occur,  I  must  not  neglect  to  say, 
that  absolute  insanity  has  in  very  rare  instances 
taken  place,  when  no  trace  of  morbid  action 
could  be  detected  in  the  brain  on  dissection.  At 
other  times,  though  not  often  till  the  near  ap- 
proach of  death,  more  or  less  coma  has  been 
present ;  but  this  has  probably  arisen,  in  part, 
from  an  impaired  state  of  the  senses,  some  of 
which  are  slightly  affected  in  about  half  the  cases. 
The  hearing  was  more  affected  than  any  other 
sense.  But  I  have  never  seen  an  instance  of  en- 
tire deafness.  A  singing  and  other  noises  were  of- 
ten heard,  especially  by  the  intemperate,  though 
they  rarely  complained  of  the  symptom.  The 
«ight  seemed  not  to  be  affected  in  most  instances, 
though  sometimes  quite  impaired.  A  transient 
dimness  of  vision  was  not  unusual,  but  subsided 
as  suddenly  as  it  supervened.  The  taste  was 
€vidently  more  obtuse ;  but  patients  generally 
answered  that  they  tasted  the  medicine,  though 
they  rarely  complained,  excepting  of  its  irrita- 
ting properties.  I  know  not  how  far  the  smell 
may  have  suffered,  as  the  patient  was  too  listless 
to  attend  to  odours. 

It  would  be  but  repetition  to  speak  again  of  the 
remarkable  ability  with  which  locomotion  was 


119 


performed  by  many  patients ;  but  there  were 
those  who  became  powerless  as  in  a  state  of  in- 
toxication. 

I  think  there  is  sufficient  evidence  to  show^ 
that  the  varying  affections  of  the  mind  and  of  the 
senses  are  not  the  result  of  any  known  morbid 
action  in  the  brain  and  nervous  system,  and  that 
these  phenomena  are  generally  less  when  they  do 
exist,  than  would  be  inferred  if  explained  on  the 
principle  of  sympathy  alone.  This  system,  there- 
fore, while  it  is  less  concerned  than  many  other 
organs,  in  the  functions  of  organic  life,  seems  to 
exist  in  a  state  of  particular  independence. 

The  Prognosis  is  always  unfavourable  in  eve- 
ry case  of  Asphyxiated  Cholera,  from  its  begin- 
ning. While  the  symptoms  of  oppression  exists 
there  can  be  no  other  than  the  most  fearful  ap- 
prehension ;  and  it  is  only  as  the  vomiting  and 
purging  cease,  as  the  pulse  begins  to  swell,  and 
the  skin  to  recover  its  warmth,  that  we  can  en- 
courage the  hope  of  a  favourable  issue  ;  and  even 
then,  the  rising  strength  and  hardness  of  the 
pulse,  the  accumulating  fur  on  the  tongue,  the 
flushed  face,  and  the  injected  eye,  often  denote 
that  the  danger  is  not  over.  Almost  any  change 
of  colour  in  the  discharges  is  auspicious,  but  par- 
ticularly as  it  inclines  to  the  darkest  shade,  when 
the  odour,  often  strong  and  offensive,  returns. 
Still,  a  putrid  smell  is  bad.  The  quantity  dis- 
charged is  surprisingly  great,  contrasted  with  the 
little  fluid  that  remains  in  the  system.  It  assumes 
a  variety  of  appearances  in  the  progress  of  con- 


120 


valescence  from  black  to  green,  and  thence  to 
yellow.  It  ultimately  seems  to  consist  of  con- 
centrated bile,  at  an  early  period  producing  heat 
and  tenesmus ;  at  a  later,  tormina  or  slight  gri- 
pings.  If  the  urine  reappear,  no  symptom  is  more 
promising.  When  the  attack  is  not  preceded  by 
diarrhcea,  active  treatment,  early  applied,  is  most 
successful  in  such  cases,  but  delay  is  generally 
followed  by  a  speedy  death.  The  beef-like 
tongue  is  always  fatal,  and  a  clean  tongue  more 
unfavourable  than  a  coated  one,  unless  occurring 
without  premonitory  symptoms.  Sordes  on  the 
teeth  denotes  the  near  approach  of  death.  I  have 
never  known  a  recovery,  where  the  temperature 
of  the  mouth  has  been  actually  below  94  degrees  ; 
and  to  this  inquiry  I  have  given  particular  atten- 
tion. Profuse  sweating  forebodes  death.  The  pre- 
sence or  absence  of  wrinkles  on  the  skin  affords 
no  indication.  Danger  is  great  in  proportion  to 
the  colour  of  the  skin,  and  the  inequality  in  the  dis- 
tribution of  heat.  A  cold  or  a  sour  breath  is  fatal ; 
great  jactation  is  fatal ;  and  so  is  coma,  or  any  con- 
siderable affection  of  the  functions  of  the  senso- 
rium.  If  complicated  with  organic  disease  of 
any  important  viscus,  death  is  certain.  The  in- 
temperate, I  believe,  die  invariably.  Sex  has  no 
influence.  Old  age  sinks  under  the  struggle, 
and  children,  if  recovered  from  collapse,  gene- 
rally die  of  subsequent  congestion  of  the  brain. 
It  is  very  difficult  to  arrive  at  any  accurate  esti- 
mate of  the  proportion  of  recoveries  from  the 
asphyxiated  disease.  The  greatest  obstacle  arises 


121 


from  the  little  discrimination  that  has  been  made 
between  premonitory  diarrhoea,  and  the  consti- 
tutional aftection,  the  former  being  regarded  as 
the  first  stage  of  the  latter.    It  is  manifest,  that 
a  great  proportion  of  reported  cures  belong  to 
the  first  class,  both  in  Europe  and  America ; 
and  it  is  from  the  success  which  generally  at- 
tends the  treatment  of  the  diarrhoea,  that  many 
worthy   practitioners  have    declared  that  they 
are  rarely  disappointed  in  the  results  of  their 
remedies.    I  think,  however,  I  gave  the  most  fa- 
vourable construction  to  this  subject  in  a  former 
letter  ;  and  from  subsequent  observation,  I  may 
safely  repeat   the  assurance,  that   the  practi- 
tioner is  eminently  successful  who  saves  one  pa- 
tient in  six,  if  Asphyxiated  Cholera  be  the  disease. 
Truth  obliges  me  to  concede  that  such  has  been 
the  melancholy  result  of  my  own  efforts,  and  I  feel 
an  equal  conviction  that  I  do  no  injustice  to  others, 
when  I  impute  to  them  as  little  success.  It  should 
be  stated  in  behalf  of  the  able  and  devoted  gen- 
tlemen who  have  presided  at  the  Hospitals,  that 
they  have  constantly  received  the  worst  subjects  of 
the  disease,  and  often  when  in  a  dying  condition. 
Still,  I  do  not  believe  there  has  been  more  honour- 
able experience  in  private  practice. 

It  is  stated  on  high  authority,  that  the  ratio  of 
deaths  in  Asia  was  only  1  in  7  or  8,  while  in  Eu- 
rope it  was  1  in  2  in  the  asphyxiated  stage,  I 
have  no  doubt  of  the  far  greater  success  of  the  An- 
glo-Asiatics from  the  absence  of  antecedent  diar- 
rhoea, which  enabled  them  to  adopt  blood-letting 

16 


122 


with  so  much  advantage  ;  but  I  must  doubt  as  to 
the  proportion  of  recoveries  which  are  said  to  have 
been  effected,  whether  in  Asia  or  Europe.  Magen- 
die  has  said  that  Cholera  begins  where  other 
diseases  end,"  and  we  find  all  authors  speaking 
in  the  language  of  despair  of  the  asphyxiated  dis- 
ease ;  save  only  the  projector  of  some  new  reme- 
dy. Dr.  Holmes,  of  Montreal,  writes  me  that, 
"  in  the  fully  developed  disease,  scarcely  any  treat- 
ment is  of  avail ;  and  this  opinion  coincides  with 
that  of  the  practitioners  with  whom  I  have  con- 
versed." 

Convalescence  was  slow,  and  often  embarrassed 
by  the  developement  of  topical  inflammation,  or 
congestion,  observing  the  following  order  in  re- 
spect to  frequency ;  the  brain,  the  liver,  the  small 
intestines,  the  stomach,  constituting  what  has  been 
rather  inconsiderately  called  typhus  fever, — and 
that,  too,  without  much  reference  to  the  particular 
organ  which  might  happen  to  become  most  involv- 
ed in  the  stage  of  reaction.  This  second  period 
of  the  paroxysm  was  almost  invariably  attended 
by  symptoms  denoting  congestion  of  the  liver,  and 
when  they  did  not  extend  to  the  other  organs,  es- 
pecially the  brain,  the  general  phenomena  were 
those  of  mild  febrile  reaction,  bearing  no  corres- 
pondence with  the  violent  irruption  of  the  cold 
stage.  The  constitutional  symptoms  were  more 
modified  by  congestion  of  the  brain,  when  the 
pulse  became  full  and  hnrd,  the  skin  dry  and  hot, 
the  tongue  dry  and  furred  over,  the  face  flushed 
and  the  eye  injected,  generally  stupor,  and  some- 


123 


times  delirium,  but  very  rarely  restlessness.  It 
was  an  obstinate  and  fatal  condition  of  disease. 
If  coma  were  not  soon  relieved  by  blood-letting, 
the  patient  gradually  sank  ;  but  partial  relief  en- 
couraged its  repetition,  and  frequently  with  suc- 
cess. Sordes  on  the  lips  and  teeth  was  a  fatal 
symptom  ;  so  was  a  small  tremulous  pulse,  pro- 
tracted respiration,  and  insensibility  of  the  eye. 

Perhaps  it  may  not  be  unacceptable  to  advert, 
in  this  place,  to  the  mode  of  practice  most  success- 
ful in  the  more  auspicious  terminations  of  the  cold 
stage,  and  what  are  denominated  its  consecutive 
diseases.  When  the  second  period  of  the  paroxysm 
ensued  without  any  particular  local  disturbances, 
it  was  constantly  necessary  to  act  with  a  reference 
to  many  possible  consequences, — particularly  to 
the  developement  of  cerebral  congestion.  But  so 
far  it  was  rather  a  system  of  watching  than  any 
active  treatment.  From  the  functional  derange- 
ment of  the  chylopoetic  viscera,  it  was  especially 
necessary  to  exhibit  cathartics  of  calomel,  and 
castor  oil,  and  to  subject  the  patient  to  a  very  rigid 
dietf  and  the  most  temperate  and  salubrious  habits. 
I  do  not  think  that  any  benefit  arose  from  the  use 
of  means  internally,  that  were  addressed  specifi- 
cally to  any  one  organ, — as  nitric  ether  to  promote 
the  secretion  of  urine,  &c.  Some  very  intelligent 
practitioners  have  employed  Dover's  powder,  either 
uncombined,  or  associated  with  calomel  ;  but  I 
have  thought  its  tendency  was  to  produce  con- 
gestion in  the  abdominal  viscera,  and  subsequently 
of  the  brain.   If  the  liver,  as  not  infrequently  hap- 


124 


pened,  became  the  seat  of  greater  disease,  either 
local  or  general  blood-letting  was  necessary,  and 
a  large  blister  over  the  region  of  that  organ.  The 
general  principles  of  treatment  were  continued. 

The  brain  being  more  constantly  the  organ  to 
which  the  local  determinations  tended,  it  was  often 
very  difficult  to  conduct  the  convalescence  of  the 
patient  safely  along.  This  complication  of  the 
disease  was  sometimes  insidious  in  its  approach, 
but  its  full  developement  was  well  marked,  and 
generally  such  as  I  have  described.  It  pursued 
the  patient  with  great  tenacity,  and  would  often 
recur  with  violence  when  partially  subdued.  Hence 
it  was  necessary  in  all  cases,  without  much  refer- 
ence to  contingent  circumstances,  to  pursue  an 
active  system  of  depletion.  General  blood-letting 
was  indispensable,  and  it  was  often  necessary  to 
repeat  the  operation  several  times,  and  that  in 
rapid  succession.  When  a  sufficient  impression 
was  made  by  this  means,  leeching  and  cupping 
came  in  with  great  advantage,  and  blisters  to 
the  neck  and  head, — the  hair  having  been  re- 
moved as  soon  as  the  brain  was  obviously 
diseased.  I  found  ice,  also,  a  useful  topical 
application.  I  exhibited  calomel  freely,  either  in 
large  or  small  doses,  according  to  particular 
indications,  some  of  which  were  especially  de- 
rived from  the  state  of  the  liver  and  bowels,  the 
former  being  always  congested  in  these  cere- 
bral affections.  Hence,  also,  blisters  over  the  ab- 
domen were  powerful  auxiliaries.  Every  sub- 
stance in  which  opium  was  an  ingredient  aggra- 


125 


vated  the  whole  train  of  symptoms.  The  warm 
bath,  not  exceeding  98  degrees,  was  useful  after 
the  vascular  action  was  subdued.  Antimonials 
and  ipecacuanha  were  excellent  alteratives  in  small 
doses,  frequently  repeated.  Rest  and  darkness 
promoted  the  good  effect  of  every  other  remedy. 

Relapses  of  the  asphyxiated  form  of  the  dis- 
ease were  less  common  than  has  been  generally 
represented  ;  and  I  am  happy  to  bear  my  testi- 
mony to  the  correctness  of  the  opinion  expressed 
by  the  medical  council,  that  "  a  second  attack  was 
not  to  be  expected."    This  opinion  has  been  cen- 
sured ;  and  doubtless,  it  was  not  sufficiently  quali- 
fied.   Cholera  Asphyxia  has  been  known  to  affect 
the  same  subject  twice  in  quick  succession,  but 
this  is  a  very  rare  occurrence.   What  are  denomi- 
nated relapses  may  be  thus  explained.    A  patient 
is  treated  for  the  premonitory  diarrhoea,  or  for  some 
other  condition  of  local  disease,  which  may  have 
been  supposed  to  announce  the  existence  of  Chole- 
ra, in  what  has  been  called  its  forming  stage  ;  and 
he  is  soon  relieved  by  his  medical  attendant.  Sub- 
sequent exposures  develope  the  constitutional  dis- 
ease, and  this  man  is  said  to  have  a  second  attack 
of  Cholera,    Or  another  patient  is  restored  from 
the  collapsed  disease,  and  the  same  exposure  sub- 
jects him  to  the  most  formidable  congestions  of  the 
abdominal  organs,  or  of  the  brain,  and  this  sub- 
ject perhaps  is  said  to  have  died  of  a  second  at- 
tack of  Cholera,  or  of  typhus  fever.   It  is  even 
a  matter  of  pride  with  the  unreflecting,  to  boast 
of  their  recovery  from  a  second  attack  ;  which  is 
found  on  inquiry  to  have  consisted  of  some  loose- 


126 


ness  of  the  bowels,  or  a  very  natural  ejection  of 
some  irritating  food  from  the  stomach.  In  this 
manner  has  arisen  the  common  impression,  that 
second  attacks  of  Cholera  are  not  infrequent. 

It  seems  almost  superfluous  to  advert  to  the 
Diagnosis  of  this  disease.  If  it  possess  no  unvary- 
ing characteristic,  it  may  be  always  distinguished 
by  the  uniform  presence  of  some  combination  of 
symptoms  that  is  strictly  pathognomonic.  It  is 
constantly  confounded  with  every  species  of  diar- 
rhoea, from  the  assumption  that  a  common  ante- 
cedent affection  of  the  bowels  is  an  integral  part 
of  the  subsequent  collapse  ;  but  none  are  so  blind 
as  not  to  distinguish  the  period  of  constitutional 
invasion.  Even  the  active  operation  of  a  cathartic 
has  subjected  many  a  worthy  citizen  to  the  dis- 
tinction of  being  a  recovered  subject  of  Cholera. 
Still  it  is  better  to  inflict  on  the  hapless  "  chole- 
rine" all  the  pains  and  penalties  that  can  arise 
from  cataplasms  to  burning  alcohol,  than  permit 
his  diarrhoea  to  persevere.  When  this  disturbance 
of  the  bowels  has  proceeded  from  atmospheric 
influence,  I  think  the  patient  is  more  regardless 
of  his  health,  than  when  it  arises  from  other 
causes. 

Ordinary  cholera  morbus  is  less  frequently 
mistaken  for  Asphyxia,  than  the  latter  is  con- 
founded with  "  premonitory  diarrhoea."  Their 
specific  difference  is  easily  distinguished. 

The  spasms  in  hysteria  are  more  like  the  clonic 
movements  of  the  muscles  in  Cholera  than  those 
of  any  other  disease  ;  and  the  coincident  sinking 


127 


of  the  pulse,  which  often  occurs  in  either  affection 
from  the  influence  of  the  spasm,  renders  a  mistake 
possible.  The  milder  disease  always  excites  great 
consternation  during  the  prevalence  of  Cholera. 

I  have  seen  the  operation  of  a  drastic  cathartic 
result  immediately  in  Asphyxiated  Cholera.  In 
such  instances,  the  patient  is  ignorant  of  his  situa- 
tion, and  awaits  the  further  operation  of  his  ill- 
directed  dose,  until  beyond  all  antidote. 

Post  mortem  appearances.  You  will  have 
seen  from  the  cases  which  I  have  heretofore 
transmitted  to  you,  that  there  exists  a  very  great 
variety  in  regard  to  the  appearances  which  are 
observed  on  dissection.  More  recent  observa- 
tion justifies  the  statement  which  I  made  you 
on  this  subject ;  but  as  that  w^as  very  general, 
I  shall  pursue  the  original  plan  of  this  letter  of 
representing  the  appearances  more  in  detail.  I 
may  now  premise,  that  I  never  detected  any  other 
remarkable  degeneration  arising  from  this  disease, 
than  what  I  have  noticed  as  existing  in  the  ali- 
mentary canal,  and  the  flabbiness  of  the  heart. 

External  appearances.  There  was  entirely 
less  tendency  to  decomposition  in  the  subjects  of 
Cholera  in  this  city,  than  in  Asia  ;  and  thus  far 
the  coincidence  is  more  with  the  European  dis- 
ease,— a  circumstance  which  may  lead  us  to  as- 
cribe something  to  the  influence  of  tropical  heat. 
I  think,  too,  that  the  evidences  of  such  change  as 
did  occur,  were  as  strongly  denoted  immediately, 
as  a  few  hours  after  death  ;  but  rather  consisted 
of  partial  disorganization  arising  from  morbid 


128 


action,  than  from  the  operation  of  chemical  laws. 
Even  the  flatus  in  the  bowels  was  not  particu- 
larly ofl)3nsive,  till  six  or  more  hours  after  death. 
It  should  be  stated,  however,  that  our  season  has 
been  unusually  cool,  and  probably,  therefore,  the 
phenomena  of  early  decomposition,  which  were 
noticed  in  the  East,  were  here  delayed  by  the 
operation  of  that  cause. 

The  body  was  generally  rigid,  and  always  so 
if  spasms  were  among  the  last  symptoms, — the  ex- 
tremities, particularly  the  arms,  being  sometimes 
in  a  contorted  position.  The  general  surface 
was  often  warmer  for  a  few  hours  after  death, 
than  when  the  patient  expired.  The  skin,  on 
the  superior  part  of  the  body,  usually  retained 
more  or  less  of  the  colour,  which  had  constituted 
one  of  the  symptoms.  Sometimes,  however,  it 
would  disappear  soon  after  death,  and  in  an  hour 
or  so  return  in  varying  shades.  It  was  common- 
ly most  remarkable  on  the  face,  scrotum,  and 
hands.  At  other  times  it  would  soon  vanish  not 
to  return  ;  or  if  the  skin  had  not  been  discolour- 
ed during  life,  it  would  generally  remain  so  after 
death, — or  in  other  instances  a  general  lividness, 
or  patches  of  blue  or  brown,  would  ensue.  The 
corrugation  of  the  fingers  remained,  though  less 
distinctly.  The  square  form,  which  I  have  no- 
ticed, was  partially  lost  in  a  more  withered  ap- 
pearance. There  was  no  remarkable  shrinking 
of  other  parts  of  the  extremities.  The  parietes 
of  the  abdomen  were  sometimes  contracted,  and 
sometimes  inflated  ; — but  more  generally  natu- 


129 


raL  The  features  were  more  shrunken  than  in 
life. 

The  Eye  was  often  lustrous  soon  after  death, 
and  commonly  turned  upwards.  It  very  rarely 
exhibited  the  film  described  by  Eastern  writers. 

The  Teeth^mA  Lips  were  frequently  covered 
with  sordes,  and  the  Tongue  often  became  opa- 
lescent after  death.  At  other  times  they  were 
natural. 

The  Muscles  were  generally  firm,  and  more 
florid,  as  soon  as  divided,  than  any  other  part. 

Abdomen,  The  stomach  and  intestines  were 
often  inflated  immediately  after  death.  Again 
there  was  nothing  remarkable,  in  this  respect,  at 
many  subsequent  hours,  and  they  were  seldom 
in  a  collapsed  state. 

Stomach,  The  exterior  of  the  organ  was  ge- 
nerally natural.  I  never  saw  it  contracted,  even 
at  its  orifices.  The  serous  tissue  sometimes  pre- 
sented a  blush  of  redness,  or  it  was  occasionally 
more  distinct  in  patches.  The  larger  vessels 
were  not  often  injected.  The  mucous  coat  was 
frequently  florid  at  one  or  both  extremities,  or 
the  redness  occurred  in  spots  of  various  shades 
from  a  crimson  to  a  deep  purple  or  black.  These 
appearances  occurred  chiefly  in  the  intemperate, 
and  were  rare  in  those  of  good  habits.  Some- 
limes  the  membrane  was  unnaturally  white,  but 
not  blanched  as  in  the  large  intestines.  It  was 
frequently  corrugated,  but  rarely  if  ever  thicken- 
ed or  softened  in  its  texture.    The  mucus  was 

17 


130 


seldom  natural,  and  not  often  superabundant. 
In  a  pathological  sense,  its  appearance  was  en- 
tirely the  most  important  phenomenon  attending 
the  organ.  It  was  about  the  consistence  of 
cream,  of  a  grayish  white,  and  more  analogous 
to  that  substance  than  to  ordinary  mucus.  It 
generally  adhered  to  the  surface,  or  when  more 
abundant,  was  intermixed  with  the  other  contents 
of  the  stomach.  I  never  observed  an  appear- 
ance of  mucous  follicles.  Among  the  contents 
of  the  organ  were  frequently  found  some  of  the 
solid  ingesta,  and  there  was  generally  more  or 
less  of  a  fluid  similar  to  that  which  had  been 
ejected.  Bile  was  sometimes  observed,  but  it 
was  a  post  mortem  occurrence,  where  it  had  not 
been  vomited.  I  have  made  no  experiments  to 
ascertain  the  presence  of  an  acid  here,  or  in  the 
intestines. 

Small  Intestines.  The  organs  generally  deno- 
ted some  morbid  vascular  action.  The  usual 
colour  presented  on  opening  the  abdomen  was 
pinkish,  a  lake  red,  and  sometimes  florid.  This 
colour  existed  most  conspicuously  in  the  inferior 
portion,  and  gradually  diminished  as  we  ascend- 
ed to  the  duodenum.  It  terminated  abruptly  at 
both  extremities,  in  most  instances.  If  it  resi- 
ded in  the  serous  membrane,  it  appeared  not  to 
exist  in  the  minute  ramifications  of  the  vessels, 
and  seemed  to  be  restricted  to  the  venous  sys- 
tem. But  in  a  great  majority  of  cases  the  serous 
tissue  was  natural,  and  the  discolouration  was  in 
the  membranes  beneath.    I  never  saw  the  mus- 


131 


cular  coat  contracted.  The  mucous  tissue,  and 
the  connecting  cellular  substance,  embraced,  in 
most  instances,  the  vascular  fulness,  which  ap- 
peared to  be  generally  limited  to  the  veins.  Some 
times,  however,  the  injection  was  very  minute, 
and  a  florid  redness  extended  over  the  whole 
surface  of  the  membrane,  here  and  there  in- 
creasing in  brightness.  It  often  resided  chiefly 
in  the  cellular  tissue  beneath. 

Again  no  trace  of  colour  could  be  detected  be- 
yond the  serous  tissue,  or  more  rarely  it  was  ab- 
sent in  both.    The  degrees  of  colour,  evidently, 
often  depended  on  the  duration  of  disease,  the  ex- 
tent of  the  evacuation,  and  the  time  of  examina- 
tion ;  but  it  was  much  less  connected  with  the 
habits  of  the  patient  than  similar  appearances  in 
the  stomach.    I  never  saw  the  small  intestines 
blanched.    The  villous  coat  was  frequently  soft- 
ened in  texture,  which  sometimes  extended  also 
to  the  serous,  and  the  former  occurred  when  there 
was  no  fulness  of  its  vessels.  In  a  great  propor- 
tion of  cases,  however,  there  was  no  such  change. 
The  membrane  was  rarely  thickened.    The  val- 
vulcB  conniventes  were  sometimes  more  than  na- 
turally prominent,  and  gave  to  the  membrane  an 
appearance  of  intumescence.    The  coats  were 
often  easily  detached  from  each  other,  and  consti- 
tuted a  pathologiac  appearance,    which  might 
happen  when  firm  in  their  texture.    The  glands 
of  Brunner  and  of  Peyer,  especially  tke  former, 
were  often  observed,  and  they  sometimes  studded 
the  membrane.    They  abounded  most  where  vas- 


132 


cular  action  was  most  obvious,  and  were  generally 
florid.  The  mucus  was  more  abundant  than  in 
the  stomach,  and  adhered  to  its  membrane  ;  or  it 
sometimes  existed  in  a  very  preternatural  quantity, 
and  was  then  intermixed  with  the  other  contents. 
It  was  usually  of  the  consistence  of  cream,  and 
still  more  like  that  substance  than  was  the 
mucus  of  the  stomach. 

The  contents  of  these  organs  varied  in  appear- 
ance, and  were  not  always  similar  to  the  dejections* 
They  commonly  resembled  the  notorious  "  rice 
water,"  or  oat  meal  gruel.  We  did  not  often  find 
the  thick  opaque  substance  filling  the  canal  as  de- 
scribed by  Christie  and  some  others.  Sometimes 
there  appeared  to  be  a  mixture  of  the  creamy 
mucus  with  the  more  fluid  contents,  and  the  floc- 
culi,  noticed  during  life,  were  often  abundant.  I 
have  seen  the  whole  tract  of  the  small  intestines 
filled  with  a  deep  yellow  fluid,  when  none  of  it  ex- 
isted in  the  large  intestines.  It  was  not  unusual 
to  observe  traces  of  bile  in  the  duodenum,  which 
had  evidently  exuded  or  had  been  pressed  into 
that  division  of  the  intestines  after  death.  The 
intestines  had  a  doughy  feeling. 

Large  Intestines,  In  these  organs  we  had  a  far 
greater  variety  in  appearances,  from  a  pinkish  hue, 
to  a  whiteness  which  arises  from  long  maceration. 
These  appearances  were  greatly  influenced  by  the 
extent  of  the  evacuations,  and  the  duration  of  dis- 
ease. There  were  observed  the  various  gradations 
between  those  extremes,  but  the  prevailing  was  a 
blanched  appearance.    At  other  times  the  whole 


133 


extent  of  the  organ  was  natural  as  in  health,  and 
some  slight  change  in  the  mucus  was  the  only  cir- 
cumstance denoting  morbid  action.  When  any 
redness  existed,  it  was  generally  in  the  cellular 
tissue,  but  red  patches  were  occasionally  noticed 
on  the  villous  coat.  The  caecum  jvas  not  particu- 
larly the  seat  of  appearances,that  did  not  generally 
exist  in  the  other  divisions.  The  mucus  was  least 
abundant  when  the  membrane  was  most  blanched, 
and  it  generally  partook  of  the  character  of  that 
which  existed  in  the  smaller  organs.  The  folli- 
cles were  not  often  enlarged,  and  when  so,  I  com- 
monly thought  that  it  was  owing  to  chronic  diar- 
rhoea. The  texture  of  the  membranes  was  rarely 
softened.  Contractions  were  occasionally  observ- 
ed, affecting  the  entire  tract  of  these  organs,  or 
only  particular  portions,  especially  the  arch  of  the 
colon.  They  were  always  very  remarkable  in  de- 
gree, sometimes  scarcely  admitting  the  finger. 
Intussusceptions  were  rarely  observed.  The  con- 
tents were  generally  watery,  of  a  light  colour,  some- 
times brown  ;  and  again  of  a  consistence  like 
cream. 

There  often  existed  on  the  serous  membrane 
of  the  intestines  a  transparent,  glutinous  fluid. 

There  was  generally  a  characteristic  appear- 
ance of  the  abdominal  viscera,  in  situ,  in  Cholera 
subjects  ;  which  chiefly  consisted  in  the  contrast 
of  colours  that  resided  in  the  two  great  divisions 
of  the  intestines. 

Liver.  No  organ  was  less  uniform  in  its 
aspect.    It  sometimes  exhibited  the  appearance 


134 


of  a  mass  of  clotted  blood,  and  again  it  was 
as  natural  as  in  health.   Between  these  extremes 
various  gradations  occurred,  and  it  was  not  unu- 
sual for  one  lobe  to  appear  more  discoloured  than 
another.    Its  serous  coat  exhibited  no  mark  of 
disease.    Organic  lesions  were  seen  in  the  in- 
temperate, but  evidently  of  antecedent  origin. 
They  did  not  appear  to  influence  the  determina- 
tion of  blood  to  this  organ.    The  most  remarka- 
ble and  uniform  appearance,  on  making  incisions 
into  its  substance,  was  the  absence  of  bile, — fre- 
quently scarcely  a  trace  being  observed.   It  was 
sometimes  gorged  with  blood,  but  more  com- 
monly contained  its  natural  quantity,  or  some- 
times appeared  exhausted  of  that  fluid.    The  ve- 
sicle always  contained  a  considerable  quantity  of 
bile,  generally  about  an  ounce  and  a  half  or  two 
ounces,  sometimes  not  half  thatquantity,  but  often 
was  rather  distended.    The  colour  varied  much, 
the  most  prevailing  being  a  greenish  yellow, — the 
extremes  being  black  and  yellow.  Its  consistence 
was  generally  natural.    The  vesicle  showed  no 
mark  of  disease  in  its  mucous  membrane.  Gall 
stones  were  not  common,  but  were  sometimes 
observed.   It  rarely  happened  that  the  bile  would 
not  flow  freely  into  the  duodenum  on  compressing 
the  vesicle,  or  that  a  probe  might  not  be  passed 
through  the  ducts. 
Pancreas  natural. 

Spleen  generally  very  natural,  but  sometimes 
gorged  with  blood. 

Kidneys  natural,  their  papillee  often  aflbrding 


135 


small  quantities  of  a  fluid  like  semi-purulent 
matter.  They  sometimes  exhibited  a  plethoric 
appearance. 

Bladder,  generally  empty,  and  very  much  con- 
tracted. In  a  few  instances  it  was  found  to  con- 
tain a  natural  urine,  to  the  amount  of  six  or  eight 
ounces.  Sometimes  a  small  quantity  of  a  semi- 
purulent-like  fluid  was  found  in  its  cavity.  Its 
lining  membrane  was  generally  natural,  but  some- 
times injected. 

Epiploon  generally  exhibited  a  fulness  of  its 
veins,  but  no  minute  injection. 

Mesocolon  and  Mesentery  had  their  veins  more 
or  less  injected  in  most  subjects,  depending  in 
some  degree  on  the  position  of  the  body  subse- 
quent to  death,  and  the  time  of  dissection  ;  as 
there  was  reason  to  think  that  the  blood  had  some- 
times returned  to  the  larger  branches  of  the  vena 
portse. 

Thorax,  There  was  nothing  uniform  in  the 
appearances  in  this  cavity.  Sometimes  the  lungs 
were  found  occupying  the  full  extent  of  it,  or 
half  collapsed,  or  compressed  into  a  withered  ap- 
pearance. When  their  volume  was  thus  remark- 
ably diminished,  it  would  have  seemed  almost 
the  indispensable  resultof  some  mechanical  cause, 
had  it  not  been  otherwise  determined  by  experi- 
ments in  the  East.  It  was  a  pathologiac  appear- 
ance which  involves  an  interesting  inquiry.  When 
their  structure  was  affected,  it  was  from  antece- 
dent disease.  In  respect  to  vascular  fulness, 
appearances  were  similar  and  equally  as  various 


136 


as  in  the  liver,  being  sometimes  surcharged  with 
blood,  and  then  again  through  all  the  interme- 
diate gradations  to  a  state  of  almost  entire 
exhaustion.  A  plethoric  state  was  sometimes 
attended  with  an  abundant  production  of  a  fluid 
within  the  bronchise. 

The  Heart  and  Blood-vessels,    T*he  heart  pre- 
sented no  other  unusual  change  than  a  frequent 
softening  of  its  texture,  by  which  it  acquired  a 
flabby  feeling  and  appearance.    Dark  patches 
were  sometimes  seen  on  its  surface.    These  were 
pathologiac  conditions  evincing  something  more 
than  impaired  nervous  energy.    The  organ  was 
rarely  injected,  even  when  the  purple  patches 
appeared.    Its  cavities  were  often  full ;  or  were 
sometimes  entirely  empty  ;  or  the  right  cavities 
were  filled  and  the  left  empty  ;  or  more  common- 
ly, a  smaller  quantity  was  found  in  both  ventri- 
cles.   The  blood  was  equally  dark  in  all  the  ca- 
vities.   If  the  ventricles  were  empty,  it  did  not 
follow,  that  the  blood  was  found  in  the  venae  ca- 
V83,  though  sometimes  considerably  accumulated 
here  ;  but  at  others,  they  were  empty,  and  it  was 
then  obvious,  that  the  blood  had  been  arrested 
in  one  or  more  of  the  great  viscera.  When  there 
was  blood  in  the  left  cavities  of  the  heart,  it  did 
not  extend  far  into  the  blood  vessels.    Even  the 
aorta  contained  but  small  quantities,  and  its  sub- 
divisions were  empty, — generally  not  even  stain- 
ed with  blood. 

The  Pericardium  was  natural. 


1S7 


There  was  no  effusion  in  the  cavity  of  the 
thorax. 

I  have  already  explained  the  appearances  of 
the  blood,  and  shall  therefore  avoid  the  repe- 
tition. 

Brain,    In  about  three  fourths  of  the  cases, 
this  organ  has  presented  a  vascular  fulness  of  its 
membranes.    The  great  sinuses  and  the  veins  of 
the  dura  mater  were  often  gorged,  and  the  pia 
mater  was  so  minutely  injected,  as  to  have  ex- 
hibited, in  some  places,  an  appearance  of  extra- 
vasation, which  indeed  might  have  existed.  Again 
there  was  observed  a  fulness  of  the  vessels  in  one 
membrane  and  not  in  the  other,  or  only  partial 
discolourations  ;  or,  in  many  instances  they  were 
perfectly  natural,  or  even  deficient  in  blood.  It 
was  not  unusual  to  observe  a  fluid  beneath  the 
arachnoid,  sometimes  rather  abundant,  but  gene- 
rally small  in  quantity.    The  brain  was  sometimes 
moist,  and  in  respect  to  consistence,  about  the 
same  varieties  occurred  as  in  subjects  of  other 
diseases*    On  dividing  its  substance,  blood  would 
sometimes  appear  in  small  dots,  and  more  abun- 
dantly when  expressed.    But  I  could  rarely  per- 
ceive that  this  was  a  pathologiac  appearance.  I 
never  remarked  any  unusual  appearance  in  the 
complex  parts  of  the  organ.    The  ventricles  fre- 
quently contained  a  preternatural  quantity  of 
fluid,  and  were  often  dry.    The  plexus  was  gene- 
rally natural,  but  sometimes  full.    I  never  dis- 
covered any  thing  worth  recording  in  the  cere- 
bellum.   The  pons  was  natural,  and  the  basilary 

18 


138 


artery  contained  black  blood.  The  nerves  were 
natural.  As  far  as  my  knowledge  extends,  the 
spinal  marrow  exliibited  no  oilier  evidence  of 
disease  than  a  fulness  of  the  exterior  vessels. 
The  ganglia  were  not  found  to  present  more  than, 
occasionally,  a  slight  redness. 

On  looking  over  the  preceding  remarks,  I  find 
that  repetitions  often  occur;  but  they  were  una- 
voidable in  a  detail  of  symptoms,  succeeding  to  a 
general  description  of  the  disease. 


Very  respectfully,  &c. 


PATHOLOGIAC  VARIETIES  OF  CHOLERA. 


LETTER  VII. 


New- York,  July  3 J,  1832. 

Dear  Sir, 

The  reports  respecting  the  existence  of 
Cholera  in  this  city  are  so  contradictory,  that 
you  may  be  desirous  of  knowing  the  absolute 
truth  ;  but  I  am  chiefly  induced  to  make  you  this 
communication  for  the  purpose  of  submitting  to 
you  the  morbid  appearances  on  dissecting  two 
individuals  who  were  supposed  to  have  died  of 
this  disease,  and  the  notes  of  which  I  took  during 
the  examination,  which  was  conducted  by  Drs. 
Carroll  and  Ludlow,  and  myself. 

The  subject  of  the  first  case  is  the  man  who 
lived  at  the  corner  of  Reed  and  Greenwich 
streets.  I  did  not  see  him  till  about  twenty  mi- 
nutes after  death,  and  have  derived  my  know- 
ledge of  his  symptoms  from  his  wife  and  his 
physician. 

He  was  forty  years  of  age,  very  robust  and  cor- 


140 


pulent — pursuing  the  trade  of  piano-forte  making 
— of  intemperate  habits,  and  had  drank  rather  ex- 
cessively on  Sunday,  the  1st  instant,  though  was 
sober  enough  to  accompany  his  wife  to  church  in 
the  evening.  He  had  complained  of  a  sense  of 
tightness  about  the  region  of  the  stomach,  for 
four  or  five  days  previously,  but  at  no  time  of 
pain  in  his  head,  before  or  during  the  disease. 
His  appetite  remained  good  till  the  noon  of  that 
day,  when  he  ate  moderately  of  fried  fish  and 
potatoes.  Soon  after  his  return  from  church,  he 
retired  to  bed,  remarking  to  his  wife  that  he  had 
an  unusual  commotion  in  his  bowels,  which  oc- 
casionally interrupted  his  sleep  till  twelve  o'clock, 
when  he  first  suffered  the  attack  of  vomiting  and 
purging,  attended  by  great  distress  in  the  ab- 
domen. 

The  house  was  immediately  deserted  by  the 
other  occupants,  and  no  messenger  could  be  ob- 
tained by  his  wife,  to  procure  a  physician,  till  five 
o'clock  in  the  morning,  at  which  time  the  patient 
was  visited  by  Dr.  Cameron.  The  doctor  in- 
forms me  that  he  found  him  violently  affected 
with  vomiting,  purging,  and  most  convulsive 
spasms;  the  features  sunken  and  the  eyes  sta- 
ring ;  the  pulse  insensible  at  the  wrist,  and  the 
surface  cold,  and  covered  with  a  clammy  sweat ; 
the  countenance  black  and  terrific ;  tongue  of  a 
dark  purple  during  the  spasms,  becoming  opa- 
lescent as  the  spasmodic  action  abated  ;  the  fluid 
rejected  was  watery,  consisting  probably  of  the 
liquids  he  was  permitted  to  drink  ;  his  dejections 


141 


resembled  rice  water,  of  the  consistence  of  cream. 
The  faculties  of  his  mind  were  unimpaired  to 
the  last,  and  during  the  short  intervals  of  ease, 
his  muscular  strength  was  not  sensibly  diminish- 
ed. He  passed  no  water  after  the  arrival  of  the 
physician. 

Small  quantities  of  laudanum  were  adminis- 
tered, and  the  usual  external  applications  made, 
with  the  effect  of  diminishing  the  symptoms  ge- 
nerally for  two  or  three  hours,  at  which  time  re- 
action began  to  take  place,  and  at  ten  o'clock  he 
was  bled  to  the  extent  of  ten  or  twelve  ounces. 
The  symptoms,  however,  had  been  again  increas- 
ing, and  continued  to  become  more  violent  till  the 
time  of  his  death,  which  took  place  about  ele- 
ven o'clock,  the  patient  having  suffered  about 
eleven  hours. 

The  lividness  disappeared  from  his  skin  about 
half  an  hour  before  death,  and  returned,  parti- 
cularly to  the  face,  about  an  hour  after  death. 

I  first  saw  him  about  twenty  or  thirty  minutes 
after  he  had  expired.  The  features  had  reco- 
vered from  their  contraction,  and  with  the  except 
tion  of  the  eye,  presented  no  unusual  aspect. 
But  the  eye  was  remarkably  expressive  of  that 
influence  which  the  disease  has  been  supposed 
to  exert  on  the  nervous  system ;  and  its  wild,  gla- 
ring stare  was  startling  to  the  spectator.  It  was 
looking  forward,  and  was  much  exposed  by  the 
contraction  of  the  eyelids. 

The  muscles  of  the  body  were  rather  rigid,  and 
the  surface  very  cold.  Spasmodic  contractions  of 
the  lower  extremities  were  still  taking  place  ;  and 


142 


I  am  informed  by  Dr.  Cameron,  that  the  legs  con- 
tinued to  move  occasionally  for  an  hour  and  a  half 
after  his  death.  The  tonfirue  and  inside  of  the 
lips  exhibited  a  dead  white,  with  a  slight  shade  of 
blue.  This  colour  was  independent  of  the  coat- 
ing, which  did  not  exist  to  any  remarkable  extent. 
There  were  several  livid  patches  on  the  thorax 
and  shoulders. 

The  dissection  was  commenced  in  about  an 
hour  and  three  quarters  after  death.  At  this  time 
the  face  had  again  become  very  livid,  and  the  skin 
was  discoloured  extensively  in  other  parts.  The 
eye  retained  its  remarkable  wildness,  much  of  which 
was  remaining  four  hours  afterwards,  when  we 
finished  the  dissection.  The  muscles  still  slightly 
rigid,  but  no  spasmodic  motion  could  now  be  ob- 
served. The  incision  penetrated  about  three 
fourths  of  an  inch  of  cutaneous  fat,  and  I  was  sur- 
prised to  find  the  muscles  so  florid  in  a  case  of  so 
much  obvious  congestion. 

On  opening  the  abdomen,  the  stomach  and 
large  intestines  appeared  very  much  inflated  ; 
the  small  intestines  only  partially  so.  The  sto- 
mach and  small  intestines  were  florid,  denoting 
great  vascularity  of  the  internal  coat.  Large  in- 
testines natural.  Mesentery  and  omentum  loaded 
with  fat.  No  turgescence  of  their  veins,  or  of  the 
veins  of  the  diaphragm.    No  fluid  in  the  cavity. 

The  stomach  contained  a  pint  of  a  fluid  resem- 
bling a  weak  infusion  of  coflee.  A  bright  redness 
existed  in  the  upper  portion  of  the  stomach,  occu- 
pying about  one  third  of  the  organ,  and  terminating 


143 


abruptly  near  the  cardiac  orifice.  All  the  inferior 
portion  was  slightly  livid,  and,  at  the  pyloric  ori- 
fice, a  livid  redness  began  abruptly,  and  extended 
through  the  whole  tract  of  the  small  intestines. 

In  the  large  intestines,  the  mucous  membrane 
w^as  natural.  A  large  quantity  of  a  fluid,  resem- 
bling oatmeal  gruel,  and  of  a  shade  between  that 
and  rice  water,  existed  throughout  the  intestinal 
canal.  There  was  rather  more  than  the  usual 
quantity  of  mucus,  resembling  cream,  though  not 
so  white. 

Liver  externally  natural — perhaps  rather  lighter 
than  usual ;  on  making  incisions,  the  black  blood 
flowed  more  freely  than  in  a  healthy  state  of  this 
organ.  The  gall  bladder  contained  about  an  ounce 
of  black  bile.  The  ducts  perfectly  natural,  the 
bile  flowing  freely  through  them.  Spleen  and 
pancreas  natural.  Bladder  empty,  but  not  par- 
ticularly contracted.  The  veins  of  the  right  auricle 
of  the  heart  rather  fuller  than  usual.  No  turges- 
cence  of  the  coronary  veins.  Lungs  blue,  and 
turgid  with  black  blood  to  a  very  remarkable  de- 
gree. Cavities  of  the  heart  and  venae  cavae  en- 
tirely empty.  No  fluid  in  the  thorax.  Brain  en- 
gorged with  black  blood,  and  the  ventricles  con- 
tained four  or  five  ounces  of  serum.  We  were  not 
permitted  to  examine  the  ganglia  and  spinal  mar- 
row. 

Case  2.  We  immediately  proceeded  to  exa- 
mine the  case  of  Betsey,  the  black  girl,  who  resided 
as  cook  at  ^Ir.  Thomas',  No.  185  Reed-street,  about 
twenty  rods  from  the  house  of  Mr,  G.,  and  where 


144 


she  had  lived  for  several  months.    Betsey  was 
very  temperate  and  regular  in  her  habits,  but  a 
large  feeder — of  slender  frame,  but  capable  of  her 
duties,  and  generally  enjoyed  good  health  ;  about 
twenty  years  of  age.    She  attended  church  in  the 
afternoon  of  Sunday,  the  1st  instant,  and  made  no 
complaint  till  six  o'clock  of  that  evening,  when 
she  felt  some  sickness  and  pain  at  her  stomach, 
and  went  to  bed.   At  two  o'clock,  A.  M.,  the  fami- 
ly were  awakened  by  her  groans.     The  morning 
after  the  examination,  I  received  from  her  attend- 
ants the  following  account  of  her  symptoms  : — 
She  was  found  stiff  with  the  cramp,  and  severely 
affected  with  vomiting  and  purging  ;  complained 
of  great  distress  over  the  whole  body ;  eyes  sta- 
ring and  sunken,  and   the  features  contracted. 
Fifteen  drops  of  laudanum  and  a  little  camphor 
were  given,  which  removed  the  vomiting  in  a  few 
minutes.    The  same  dose  was  repeated  in  an  hour 
after.    The  purging,  however,  continued;  and  the 
spasms  constantly  recurred,  attended  by  great  suf- 
fering.    Profuse  sweating  took  place  towards 
morning,  when  the  surface  became  rather  warmer. 
At  eleven  o'clock,  she  began  to  sleep,  and  was  then 
left  by  her  attendants  till  four  o'clock,  at  which 
time  she  was  found  dying. 

The  fluid  vomited  and  dejected  is  said  to  have 
resembled  rice  water.  She  had  no  physician. 
In  the  progress  of  the  disease,  a  dose  of  salts 
was  given,  and  occasionally  wine  and  water. 

The  dissection  was  commenced  at  fifteen  or  twen- 
ty minutes  after  death.  Every  muscle  was  violently 


145 


contracted,  and  remained  so,  without  any  motion, 
however,  for  an  hour  and  a  half,  when  the  exami- 
nation was  finished.  Skin  Hvid,  and  petechise 
numerously  distributed,  appearing  with  great  dis- 
tinctness on  the  schlerotic  coat  of  the  eye.  Fea- 
tures rather  sunken  ;  expression  of  the  eye  re- 
markably wild  and  glaring,  corresponding  exactly 
with  this  appearance  in  the  other  case.  The 
eyes  were  also  very  much  exposed,  and  turned  up- 
wards. 

The  stomach  and  large  intestines  externally 
natural,  and  free  from  flatus.  Small  intestines 
livid.  Veins  of  the  omentum  and  mesentery  more 
than  usually  full.  Mucous  coat  of  the  stomach 
slightly  discoloured ;  scarcely  a  morbid  appear- 
ance. This  organ  contained  a  small  quantity  of  a 
fluid  resembling  rice  water.  The  lividness  of  the 
small  intestines  existed  in  the  serous  membrane, 
the  mucous  coat  being  natural.  These  organs 
contained  a  considerable  quantity  of  a  yellow 
fluid.  The  large  intestines  were  filled  w4th  a  fluid 
exactly  resembling  rice  water,  with  flocculi  like 
*Mialf-dissolved  flakes  of  snow."  Mucous  mem- 
brane natural.  The  mucus,  which  resembled  a 
creamy  substance,  did  not  exceed  the  natural 
quantity. 

Liver  very  purple — the  left  lobe  in  a  plethoric 
state,  and  the  right  lobe  very  turgid,  with 
black  blood.  The  gall  bladder  contained  about 
an  ounce  of  yellow  bile.  The  ducts  perfectly 
natural.  Spleen  and  pancreas  natural.  Uri- 
nary bladder  contracted  to  a  small,  hard  knot,  evi- 

19 


146 


dently  owing  to  the  spasm.  No  fluid  in  the  cavity 
of  the  abdomen.  The  lungs  were  found  in  a 
perfectly  natural  state.  The  heart  was  engorged 
with  black  blood,  as  were  also  the  vense  cavse. 
No  fluid  in  the  thorax.  We  were  too  much  fa- 
tigued to  enter  on  the  examination  of  the 
brain,  &c. 

July  4. — Cases  of  this  disease  are  now  con- 
stantly occurring,  and  it  attacks  all  ages  from  in- 
fancy. The  symptoms  are  uniformly  such  as  I 
have  described.  Dr.  Bliss  informed  me  to-day 
that  he  witnessed  the  dissection  of  a  child,  in 
which  the  morbid  appearances  were  exactly  such 
as  I  have  described  in  Betsey's  case.  The  inva- 
sion is  very  sudden,  and  without  any  premonitory 
symptoms.  I  believe  some  have  recovered.  They 
generally  die  in  about  twelve  hours  from  the  at- 
tack. It  has  now  appeared  in  almost  every  part 
of  the  city,  and  no  one  thinks  of  tracing  it  to  con- 
tagion. The  vomiting  is  easily  allayed  by  small 
doses  of  laudanum.  The  spasms  are  obstinate. 
The  collapse  is  immediate,  and  no  reaction  takes 
place*  In  short,  it  is  death  at  the  very  invasion. 
The  probable  number  of  deaths  to  this  time,  six 
P»  M,,  is  from  thirty  to  forty. 


Very  respectfully,  &c. 


147 


LETTER  VIII. 


New-York,  August  Ibth,  1832. 

Dear  Sir, 

I  have  just  attended  an  examination  of  one  of 
the  most  malignant  cases  of  Cholera  Asphyxia  that 
I  have  yet  witnessed  ;  and  perhaps  you  may  be 
interested  with  an  account  of  the  morbid  appear- 
ances. 

The  subject  was  a  very  robust  sailor,  about  forty 
years  of  age,  and  of  intemperate  habits.  He  was 
attacked  with  vomiting  and  purging  on  the  even- 
ing of  the  12th  inst.,  and  was  found  in  a  shed  on 
the  following  morning,  from  whence  he  was  taken 
to  the  Park  Hospital,  where  he  died  in  a  very  short 
time.  The  purging  was  now  slight,  but  the  vomit- 
ing and  spasms  were  excessively  severe.  He  had, 
also,  the  other  characteristic  symptoms  of  the  dis- 
ease in  a  prominent  degree.  Almost  the  entire 
surface  of  his  body  was  nearly  black. 

The  examination  was  commenced  about  ten 
hours  after  death.  The  surface  of  the  body  still 
retained  its  blackish  hue,  and  the  muscles,  as  is 
common,  were  very  rigid.  As  their  substance 
was  divided,  we  observed  the  redness  which  they 
usually  present  in  this  disease,  which  contrasts 


148 


very  strongly  with  the  blood  in  the  larger  arteries. 
The  stomach  was  unusually  capacious  and  rather 
florid.  The  small  intestines  were  of  a  dull  pink- 
ish hue,  which  became  less  obvious  in  the  larger. 
These  organs  were  all  inflated,  but  nowhere  con- 
tracted. The  veins  of  the  omentum  and  mesen- 
tery were  fuller  than  in  the  natural  subject,  and 
there  was  an  obvious  determination  of  blood  to 
these  viscera.  The  stomach  contained  about  three 
gills  of  a  fluid  similar  to  the  contents  of  the  gall 
bladder,  which  had  evidently  exuded  from  the 
liver  since  the  death  of  the  subject,  as  the  fluid 
vomited  exhibited  the  appearance  of  rice  water 
to  the  last  moment  of  life.  There  were  florid 
patches  distributed  on  the  mucous  membrane, 
and  its  veins  were  fuller  than  natural.  But  I  have 
generally  seen  these  appearances  only  in  the  in- 
temperate. I  examined  the  texture  of  this  mem- 
brane through  the  alimentary  canal,  and  we  were 
satisfied  that  it  was  not  softened,  or  in  any  respect 
disorganized,  the  reverse  of  which,  however,  I  have 
observed  in  cases  of  apparently  much  less  malig- 
nancy. The  pyloric  orifice  was  in  a  healthy  state? 
as  was  also  the  cardiac.  The  mucus  was  natural 
in  appearance  and  quantity,  and  equally  so  in  the 
intestines.  The  mucous  coat  of  the  small  intes- 
tines was  fully  injected,  and  the  blood  florid,  ap- 
pearing more  like  inflammation  than  congestion  ; 
though  certainly  not  active  inflammation.  The 
large  intestines  were  hardly  in  a  pathologiac  state, 
and  manifested  no  particular  vascularity  at  the  caput 
coli.    These  organs  contained  a  light-coloured 


149 

fluid.  The  liver  was  unusually  large,  of  a  hard- 
ened texture,  very  natural  in  colour,  and  contain- 
ing rather  less  than  its  natural  quantity  of  blood. 
The  gall  bladder  was  full  of  a  greenish  yellow 
fluid,  and  its  ducts  entirely  pervious.  The  kidneys, 
spleen,  and  pancreas,  natural.  The  bladder  mode- 
rately contracted,  and  containing  more  than  half 
an  ounce  of  a  fluid  resembling  thin  pus.  The 
lining  membrane  was  morbidly  vascular,  of  a 
bluish  appearance,  but  we  could  not  detect  any 
evidence  of  gonorrhoea.  The  veins  of  the  dia- 
phragm were  not  full.  The  lungs  filled  the  cavity 
of  the  thorax.  (We  frequently  find  them  very 
much  contracted  and  empty.)  They  were  black 
and  greatly  engorged  with  blood.  There  exuded 
from  the  incisions  a  large  quantity  of  a  muco- 
serous  fluid.  Their  structure  was  healthy.  The 
heart  was  natural,  and  contained  in  both  ventricles 
black  blood.  The  large  arteries  remote  from  the 
heart,  as  is  common  in  our  examinations,  were 
entirely  empty,  not  even  stained  with  blood. 
There  was  no  eff'usion  in  the  thorax,  or  other 
cavities.  The  brain,  quite  unexpectedly  to  us, 
exhibited  the  most  perfect  appearance  of  health. 
Its  blood  was  not  even  so  much  discoloured  as 
in  other  organs,  and  there  was  no  more  than  its 
natural  proportion.  There  was  no  eff'usion  under 
the  membranes,  and  the  ventricles  were  only 
moist. 

Very  respectfully,  &c. 


150 


LETTER  IX. 


New-Yokk,  August  BOthy  1832. 

Dear  Sir, 

I  ATTENDED  this  moming — at  the  Crosby- 
street  Hospital,  through  the  politeness  of  Dr. 
Rhinelander,  who  has  the  charge  of  that  insti- 
tution, and  where  I  have  before  witnessed  very 
interesting  dissections — the  post-mortem  exami- 
nation of  two  subjects  who  died  of  Cholera,  and 
whose  cases  I  communicate  to  you,  for  the  pur- 
pose of  announcing,  if  I  am  not  mistaken,  the  dis- 
covery at  that  hospital  of  an  oil  existing  in  a  free 
state  in  the  blood.  I  have  not  seen  this  circum- 
stance noticed  by  any  writer  ;  or  if  so,  I  have 
forgotten  the  fact.  Dr.  Gale,  the  chemist  em- 
ployed by  Dr.  Rhinelander,  is  the  gentleman  who 
first  observed  this  phenomenon,  and  who  has 
witnessed  it  in  many  instances.  He  has  oblig- 
ingly furnished  me  with  his  notes  on  the'  sub- 
ject, which  I  shall  append  to  the  cases.  Per- 
haps, too,  you  may  derive  some  interest  from  the 
novelty  of  one  of  the  patients  having  been  trans- 
fused. 


151 


A.  B.,  an  athletic  negro,  aged  about  forty 
years,  employed  as  a  sailor,  and  of  intempe- 
rate habits,  was  admitted,  on  the  morning  of  the 
29th,  with  the  usual  phenomena  of  Malignant 
Cholera.  Vomiting  and  purging  had  occurred  to 
a  large  extent.  He  died  at  three  o'clock  in  the 
afternoon,  and  the  dissection  was  commenced 
about  eighteen  hours  after  death.  There  was 
nothing  remarkable  in  the  external  appearance 
of  the  body.  The  muscular  substance  presented 
the  usual  florid  appearance.  No  sensible  decom- 
position had  taken  place.  The  veins  of  the  epi- 
ploon and  mesentery  more  than  naturally  full. 
Small  intestines  of  a  pinkish  colour  ;  large  intes- 
tines nearly  natural — not  blanched  ;  caput  coli 
natural.  These  organs  had  a  glutinous  fluid  on 
their  exterior,  which  is  often  observed.  The 
mucous  tissue  of  the  small  intestines  rather  flo- 
rid, but  not  minutely  injected — the  blood  evi- 
dently existing  in  the  veins  ;  its  texture  firm,  but 
not  very  grumous  ;  the  quantity  of  mucus  natu- 
ral, but  creamy.  The  contents  of  the  whole 
tract  consisted  of  a  large  quantity  of  a  fluid  re- 
sembling oatmeal  gruel.  There  was  nothing 
unusual  appertaining  to  the  large  intestines.  The 
liver  was  very  natural,  and  the  gall  bladder  about 
half  full  of  a  light-coloured  bile,  which  escaped, 
on  pressure,  into  the  duodenum.  There  were 
also  found  three  gall  stones,  of  the  size  of  a  pea, 
in  the  duct.  Bladder  contracted,  and  containing 
about  two  drachms  of  a  turbid  yellowish  fluid  ; 
quite  vascular  at  its  posterior  part.  Kidneys 


152 


very  large,  but  natural ;  a  semi-purulent  fluid 
oozed  from  the  papillae.  Spleen  flabby,  and  full 
of  blood.  Pancreas  natural.  The  anterior  por- 
tion of  the  lungs  contained  more  than  the  natu- 
ral proportion  of  blood,  and  the  posterior  still 
more — making  a  proper  deduction  for  the  posi- 
tion of  the  subject.  The  lungs  otherwise  healthy. 
The  heart  in  all  its  cavities,  and  the  large 
vessels,  contained  a  considerable  quantity  of 
black  blood.  The  substance  of  the  heart  was 
soft  and  flabby,  otherwise  natural.  Numerous 
masses  of  firm  coagulable  lymph  were  found  in 
this  organ,  and  in  the  aorta  at  its  origin — a  cir- 
cumstance which  frequently  occurs,  even  when 
dissections  are  made  soon  after  death. 

No  fluid  in  any  of  the  cavities. 

The  brain  was  perfectly  natural — no  fulness  of 
its  veins — perhaps  rather  less  serum  than  should 
have  existed.  The  arteries,  as  usual  in  choleric 
subjects,  contained  black  blood.  The  par  vagum 
and  other  nerves  very  natural. 

The  oil,  to  which  1  have  adverted,  was  remark- 
ably abundant  in  this  subject.  It  covered  the 
blood  from  whatever  part  abstracted,  and  floated 
in  small  and  large  globules  on  the  surface  of  about 
one  ounce,  after  standing  an  hour  in  a  vessel, 
into  which  it  had  been  received  from  the  heart. 
There  were  two  globules  of  the  size  of  a  common 
pea;  the  others  were  very  numerous,  but  no  larger 
than  a  grain  of  mustard.  It  was  found  in  the 
large  and  small  vessels — it  was  very  distinct  in 
the  brain — it  was  as  obvious  in  the  kidneys,  and 


153 


in  every  part  particularly  examined.  It  resembles 
olive  oil  in  appearance  and  consistence. 

Case  2. — The  subject  of  this  case  was  a  white 
man,  aged  thirty-five  years,  a  labourer,  and  in- 
temperate. He  was  admitted  in  the  forenoon  of 
the  29th  inst.,  and  died  at  eight  o'clock  in  the 
evening.  His  symptoms  were  very  malignant,  and 
presented  a  good  specimen  of  the  Asiatic  Chole- 
ra. He  was  transfused,  five  hours  before  death, 
with  forty  ounces  of  the  common  saline  prepara- 
tion. Dissection  began  fifteen  hours  after  death. 
No  particular  evidence  of  decomposition.  Body 
still  quite  livid.  Muscles  more  than  usually  florid. 
Large  veins  of  the  abdominal  viscera  rather  fuller 
than  natural.  The  omentum  more  than  usually 
vascular  and  florid.  The  stomach  externally  and 
internally  natural — no  fulness  of  its  vessels,  and 
no  softening  of  the  mucous  tissue.  Small  intes- 
tines of  a  light  blush  of  redness,  but  scarcely 
pathologiac ;  inner  membrane  rather  more  than 
naturally  vascular,  and  the  blood  existing  in  the 
extreme  vessels  ;  its  texture  firm,  and  distributed 
on  its  surface  were  numerous  enlarged  follicles. 
The  mucus  here,  as  in  the  continuous  organs, 
natural  in  quantity,  and  of  a  creamy  consistence 
and  appearance.  Large  intestines  perfectly  na- 
tural. These  organs  were  much  inflated,  and  con- 
tained a  large  quantity  of  a  light-coloured  fluid, 
intermixed  with  a  pultaceous  substance.  Their 
surface  was  covered  with  a  transparent  glutinous 
fluid.  In  the  stomach  were  found  several  large 
pieces  of  pickled    cucumber,  which  had  been 

20 


154 


swallowed  without  mastication.  In  the  large  in- 
testines, as  also  in  the  other  subject,  the  mucous 
tissue  was  easily  detached,  by  pulling,  from  the 
serous.  Not  so  in  the  small  intestines.  I  have 
often  remarked  this  circumstance  in  other  sub- 
jects, and  have  found  it  existing  in  the  small  in- 
testines. The  liver  was  natural,  and  the  gall  blad- 
der distended  with  black  bile,  which  was  easily 
expressed  into  the  duodenum.  The  kidneys  na- 
tural, and  the  same  muco-purulent  fluid  as  in  the 
other  case  exuded  from  the  papillae  in  a  small 
quantity.  Spleen  and  pancreas  natural.  The 
bladder  was  not  contracted,  and  it  contained  half 
a  pint  of  a  light  straw  coloured  urine.  This  is 
the  first  instance  in  which  I  have  found  more  than 
half  an  ounce  of  that  fluid.  The  lungs,  posteriorly, 
were  gorged  with  black  blood  ;  their  structure 
healthy.  The  cavities  of  the  heart  and  large  ves- 
sels contained  rather  a  large  quantity  of  hlack 
blood,  in  which  were  discovered  large  concrete 
masses  of  coagulable  lymph — some  of  them  in  the 
aorta,  and  some  in  the  pulmonary  artery.  The 
substance  of  the  heart  was  soft  and  flabby,  and  a 
few  purple  patches  were  observed  on  its  surface — 
an  appearance  which  is  not  common  with  us. 
The  brain  was  in  all  respects  natural  ;  its  con- 
sistence usual ;  the  blood-vessels  not  half  filled  ; 
but  there  was  more  than  half  an  ounce  of  serum 
in  the  ventricles. 

In  this  subject  the  free  oil  was  seen  floating  on 
the  blood  which  was  taken  from  the  heart,  from 
the  kidneys,  the  brain,  &c. ;  but  in  less  remarka- 


155 


ble  quantities  than  in  the  former  case.  I  coukl 
perceive  no  difference  in  the  colour  of  the  blood 
of  this  injected  subject,  from  what  occurs  in  all 
cholerics,  excepting  in  the  minute  vessels  of  the 
membraceous  organs,  and  in  the  brain,  where  it 
was  more  florid.  I  think,  also,  the  fluidity  was 
greater,  although  the  quantity  transfused  was  not 
large. 

In  an  unfinished  letter  to  you,  I  have  adverted 
to  the  dissection  of  another  transfused  subject,  in 
which  the  appearances  are  nearly  coincident  with 
this  case. 

The  following  is  the  statement  referred  to  from 
Dr.  Gale  :— 

Dr,  31.  Paine, 

Dear  Sir, — Your  request  concerning  the  oily 
matter  which  I  have  noticed  in  the  blood,  I  am 
happy  to  gratify,  as  far  as  I  am  able.  The  oily 
matter  referred  to  above,  is  not  that  described  by 
Lecanu,  as  discovered  by  Schwilgue.  The  former 
is  obtained  by  solution  of  the  solids  contained  in 
the  blood,  in  alcohol ;  the  latter  is  found  floating 
on  the  surface  of  the  blood  when  taken  from  the 
body.  The  proportions  vary  with  the  stage  of 
the  disease,  increasing  as  it  is  more  advanced. 
Indeed,  I  have  scarcely  found  any  appreciable 
amount  in  patients  that  were  not  in  a  stage  of  col- 
lapse. It  is  greater  after  death  than  the^usual  in- 
creased proportion  would  furnish ;  or  in  other 
words,  the  proportion  is  a  constantly  increasing 
one.    The  case  you  saw  here  last,  I  think,  is  a  fair 


156 


sample  exhibited  by  post  mortem  examinations. 
The  portion  of  the  oily  matter  in  eight  cases  has 
been  from  one  half  to  two  per  cent.,  which  is  the 
greatest  proportion  I  have  seen  in  any  case. 

The  matter  above  mentioned,  I  believe,  has  not 
been  described  by  any  writer  on  the  subject ;  and 
though  I  have  by  no  means  found  it  in  all  the  pa- 
tients examined,  and  from  whom  I  have  taken 
cholera  blood,  yet  in  every  case,  except  one,  of 
post  mortem  examination,  I  have  perceived  the 
oily  matter,  sooner  or  later,  floating  on  the  surface 
of  theblood. 

I  have  not  yet  ascertained  whether  it  be  a  pecu- 
liar principle,  or  whether  it  be  only  the  same  as 
that  described  by  Lecanu,  I  shall  examine  this 
matter  as  soon  as  I  find  leisure. 

Respectfully  yours,       L.  D.  Gale. 

The  case  alluded  to  as  "  a  fair  sample,"  is  that 
of  the  sailor.  The  blood  was  rather  more  than 
usually  abundant  in  the  heart  and  large  vessels, 
of  diminished  fluidity,  and  very  dark  in  the  arte- 
rial system. 


Very  respectfully,  &c. 


157 


LETTER  X. 


New-York,  September  Uh,  1832. 

Dear  Sir, 

I  HAVE  endeavoured  to  communicate  to  you 
hitherto,  such  of  the  cases  of  Cholera  Asphyxia, 
in  which  I  have  made  or  have  witnessed  post 
mortem  examinations,  as  should  best  illustrate 
the  pathologiac  varieties  which  occur  in  that  dis- 
ease. Parallel  cases  would  but  encumber  the 
Journal  in  which  you  have  done  me  the  honour  of 
making  the  publication,  and  would  afford  no  in- 
terest to  yourself  from  the  multiplicity  which  are 
now  on  record. 

Through  the  continued  politeness  of  my  friend, 
Dr.  Rhinelander,  I  assisted  in  the  dissection  of 
a  subject  at  the  Crosby-street  Hospital  this  morn- 
ing, whose  case  adds  to  the  variety  of  morbid 
appearances  which  have  fallen  under  my  obser- 
vation. 

The  subject  was  a  labourer,  about  forty-five 
years  of  age,  and  his  habits  generally  temperate. 
He  was  admitted  yesterday  in  the  stage  of  col- 
lapse ;  and  after  suffering  severely  the  usual  cha- 


158 


racteristic  symptoms,  died  in  the  evening.  The 
examination  began  about  twelve  hours  after 
death.  Surface  natural,  features  contracted  ^ 
muscles  rigid,  abdomen  tumid.  Stomach  and 
small  intestines  inflated,  the  latter  more  than 
usually  florid.  Veins  of  the  epiploon  and  me- 
sentery full.  Peritoneal  investment  adhesive 
to  the  touch.  Mucous  membrane  of  the  sto- 
mach natural,  of  the  small  intestines  slightly 
vascular,  but  the  redness  existed  principally  in 
the  serous  tissue.  As  is  common  in  Cholera 
subjects,  where  redness  of  the  small  intestines 
occurs,  it  abounded  most  in  the  ilium.  There 
was  little  else  in  the  canal  than  a  cream-like  mu- 
cus, which  was  found  in  a  preternatural  quanti- 
ty, but  adhering  to  the  membrane.  The  large 
intestines  were  contracted  through  their  whole 
extent  to  about  two  thirds  of  an  inch  in  diame- 
ter. The  coecum  was  also  contracted  in  a  cor- 
responding degree.  They  of  course  presented 
a  knotted  appearance.  The  colour  was  healthy, 
and  in  every  other  respect  they  were  perfectly 
natural.  They  contained  nothing  but  mucus, 
less  abundant  than  in  the  smaller  portion,  but 
very  similar  in  sensible  properties.  This  is  the 
second  instance  only  in  which  I  have  observed  a 
contraction  of  the  large  intestines.  The  former 
I  noticed  in  a  subject  at  the  Bellevue  Hospital, 
and  in  that  case  the  contraction  was  confined  to 
the  arch  of  the  colon.  This  portion  of  the  intes- 
tines is  commonly  found  inflated — very  rarely 


159 


contracted.  The  liver  was  unusually  pale,  and 
no  blood  flowed  from  deep  incisions.  It  could 
only  be  expressed  from  its  largest  veins.  We 
could  not  detect  a  trace  of  bile  in  the  organ  ;  it 
was  otherwise  healthy.  The  gall  bladder  con- 
tained about  an  ounce  of  yellowish  bile — appa- 
rently two  thirds  filled.  Urinary  bladder  entire- 
ly contracted.  The  other  abdominal  viscera  na- 
tural. In  the  thorax,  the  lungs  were  very  natu- 
ral, and  about  two  thirds  exhausted  of  air.  The 
left  cavities  of  the  heart  were  perfectly  empty  and 
natural ;  the  right  contained  a  moderate  quanti- 
ty of  blood,  and  were  morbidly  flabby.  No  pe- 
techise.    Serous  tissues  of  the  parietes  natural. 

Dr.  Rhinelander  made  a  very  minute  dissec- 
tion of  the  brain.  It  was  rather  more  than  usu- 
ally soft,  and  its  organization  was  distinct,  and 
exhibited  in  a  very  interesting  manner  by  Dr.  R. 
The  membranes  were  natural,  and  their  veins 
contained  less  blood  than  is  commonly  found  in 
subjects  who  have  died  of  other  diseases.  The 
nerves,  in  their  origin  and  extension,  showed 
no  mark  of  disease,  nor  could  any  be  detected 
in  the  cerebral  substance.  A  little  florid  blood 
exuded  on  the  surface  of  the  medullary  portion. 
The  ventricles  contained  their  proper  quantity  of 
fluid,  and  the  plexus  was  natural.  The  pineal 
and  pituitary  glands,  and  other  parts,  were  found 
in  their  natural  state.  The  cerebellum  and  me- 
dulla oblongata  were  equally  free  from  marks  of 
disease,  and  the  basilary  artery  was  empty. 


160 


In  this  subject,  the  oil  of  which  I  formerly 
spoke  was  found  in  small  quantities  on  the  blood, 
from  whatever  part  examined. 

No  evidence  of  decomposition. 

Very  respectfully,  &c. 


THE  END 


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